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Full text of "guys hospital reports"

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GUY'S HOSPITAL 
REPORTS. 



XDITES BT 

H. G. HOWSE, M.S, 

ABD 

FREDERICK TAYLOR, M.D. 



C^itb Sttiti. 

VOL. XXV. 




LONDON: 
J. « A. CHURCHILL, NEW BDRLINGTOH STREET. 



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CONTENTS. 



I. On Purpura HKmorrli&gica, accompaDjing the 
Growth of Multiple Sarcomata. B7 C. Uiltoit 

pAflQB, M.D 1 

II. ThenDometric Scalea. BjThohas Stetbuboit, M.D. 21 
m. DutenBion of the Frontal Sinus, By Chablbs 

HieoEiTS . . . . .27 

IT. ITote on the Triangular Ligament of the Urethra. 

By B. B. CAEEDf8T0N, M.D. . . .41 

T. Beflex Action in DiagnoBia. Bj P. Hobbockb, M.D. 61 
TI. A Second Case of Fracture of the Skull, followed by 
a Collection of Cerebro-Bpinsl Fluid beneath the 
Scalp. By B. CiEUENT Litoab, B.a. . . 91 

Til. A Case of OBteitia Deforouuu. By C. J. Sthotdb, 

M.S. 99 

Tm. On the Bheuniatic DiathesiB in Childhood. By 

jAMiB r. GfoODHABT, M.D. . .108 

IX. Alopecia Areata. By P. H. Pte-Smitb, M.D. . 189 
Z. On the Fatal Termination of Diabetea, with especial 
reference to the Death by Coma. By Fbsdsbioe 
Tatiob, M,D 147 

XI. ObBerrations on the Tariona Forms of Superficial Der- 
matitis, particularly Erythema, Eczema, PaoriaaiB, 
Lichen, and Fityriaaia Bubra. With Casea. By 
P. H. Ptk-Skith, M.D. . . . .205 

XII. On Three Cases of "Beduction en Masse." By N. 

Datixb-Collxt, M.C. .... 285 



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IT Contents. 

XIII. Cbronic Brigbt'i Diaease without Albumionris. 3j 

By F. A. Mahombd, M.D. . . .295 

XIY. On a Eemarkable instance of Hereditary tendency to 
the Production of Supernumerary Digits. By B. 
Clkheitt Ltfcab, B.S. .... 417 
XV. Od Chronic Nasal Obstruction. I. Ozena. II. 
Adenoid Growths of the Naso-pWynz. By C. H. 
GoLDiuG-BiED, B.A., M.B. . .421 

Xyi. Statistical Account of the Surgical Treatment of 
Aneurism. Collected from the Hospital Eecords. 
By Chabtess J. Symohdb, M.S. , . . 447 

XVII. An Inquiry into the Fhyaiognomy of Fhthisia by the 
method of " Compoaite Fortraiture." By Fbutcib 
Galtoh, F.B.S., and F. A. Maboubd, H.D. . 476 
XVin. On some Fointe in relation to Intra-ocular Glioma. 

By A. W. Bbailkt, M.D. . . .495 

List of Pupila wbo haTO passed the Examinations of 

the several Universities, Colleges, Ac, during 1879 601 
List of Medallists and Friiemen, 1S76-79 . . 607 

List of Pupils who have received Appointments at 

Guy's Hospital during 1879 . . . 608 

List of Pupils who have passed the Examinations of 

the aeveral Universities, Colleges, Ac., during 1880 514 
List of Medallists and Prizemen. 1879-80 . . 619 

list of Pupils who have received Appointments at 
Gny's Hospital during 1880 . , . 620 



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LIST OF PLATES. 

TO lAOl 
Mfll 

Ms. LvcAJ. 

FUte, illnitrating his caee of Fracture of tbe Skull 9S 

Mb. Sfxokbb. 

Plato, ebowing left arm of patient affected with OsteitiB 

Deformans ..... 101 

DB. MXKOiCED. 

Plates I and II, illastrating his paper on Chronic Bright's 

disease without Albnminuna 418 

Mb. Lucas. 

Chart, illustratiiig bis paper on Hereditary Tendencj to 

the production of Supernumenuy Digits . . 418 

Mb. Gllios and Db. Mabohbs. 

Plates I, U, III and IT, illustrating cases of FhthisiB b; 

the method of Composito Portraiture . . 491 

Db. Bbailet. 

Plates I and II, illustrating his paper on Intra-ocular 

Glioma .500 



LIST OF WOODCUTS. 

FAAB 

Db. Cabbdioton. 

Two Woodcuts, illustrating the Anatomy of the Triangular 

Ligament of the Urethra . 41 to 49 

Db. Hobboces. 

Two Woodcuts, illustrating his paper on Beflez Action 

in Diagnosis . 62 to 6S 

Db. Mahoues. 

Twenty Woodcuts, illustrating Sphjgmogrophic tracings 

in Chronic Bright's disease . 330 to 410 

Mb. GoLDwa-BiED. 

Two Woodcuts, illustrating his paper on Chronic Nasal 

Obstruction. . 440 and 444 



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NOTICE TO SUBSCRIBERS. 



Tenni of SoburiptioD, iucludiog postage or delivery : 

a. d. 
In Great BritaiD, nnd to Conntriea within the 

Poat&l Union . . . .60 

To the Colonies, and to India .70 

TermB to Nan-HuhBcriben , .76 

SobscriptioDB are doe immediately HfHm rteeipt of tke volume. 
FoBt-offlce orden should be drawn in favoor of Mr. Henry Howse, 
made payable at the Borough High Street Poat Office, and addressed 
to 10, 8t. Thomas's Street, Southwark, London, 8.E. ; they may with 
adfantage be crossed "and Co." 

A printed and numbered receipt will in all cases (except for foreiga 
Sabscriptions) be sent to the Subscriber immediately on receipt of hia 
ntmittance. If the Subscriber does not receive this within four days, 
he is requested to communicate at once with Dr. Frederick Taylor, 
U, St. Thomas's Street, Southwark, S.E. In this way the Editors 
hope that all mistakes, of whatever kind, will he at once detected and 
investigated. The safe receipt of foreign remittances from countries 
within the Postal Union will be acknowledged by postal card. 
Changes of address, or any other corrections in the list of Sub- 
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It is not, however, necessary to notify to the Editors each year the 
Subscriber's wish to continue on the list, as no name will be erased ao 
long as the volumes are duly paid for, unless at the express desire of 
the Subscriber. 

In couseqaeuce of the regulations of the Postal Union, it is 
necessary to keep the weight of the volume below 2 lbs., so that it mfty 
rea^y be sent to countries within the Union, 



NOTICE. 



Somewhat imperfect sets of the First and Second Series of the 
Reports can be had at very reduced prices on application to the 
Editors. 



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LIST OF SUBSCRIBERS. 



Aberdeen, Medico-Cbirargical Society, The Libnu?, Medical H&Il, 39, 

EiDg Street, Aberdeen 
Abbott, George, 23, Fjnsbury Circoa, E.C. 
Adam, Mercer, M.D., The ChurchyBrd, Boston, Lincolnehire 
Adamt, Matthew A., Ashford Road, Maidatoue 
Aikin, CbarLea A., 7, Clifton Place, Satsei Sqaare, W. 
Aikin«, M. H., M.D,, Bnrnhamthorpe, Ontario, CHanda 
Alcock, Thomas, M.D., Oakfield, As bton- upon- Mersey, Manchester 
Andrews, Eichard J., Beaufort Place, St, Thomas's, Exeter 
Arminion, W, B., M.D., Clifton Grove, Agnew Street, Lytham, 

Lancashire 
Aehby, Alfred, M.B., (Grantham, Lincolnshire 
Ashby, Heury, M.D., Guildhall Chambers, Lloyd Street, Albert Square, 

Manchester 
Atkins, F. D., High Street, Sutton, Surrey 
Atkins, F. T., 1, Bedford Terrace, Plumstead, Kent 
Atwell, Oregory H,, Church Street, Altrinchsm, Cbesbire 

Bacon, George Mackenzie, M.D., Asylum, Fulbourne, Cambridge 

Bader, C, 10, Pinsbury Circus, E.C. 

Bagnall, S. Freeman, 1, Clarence Terrace, Runcorn, Cheshire 

Baird, Andrew W.,M.D., 7, Camden Crescent, Dover 

Baker, A. de Winter, Dawlish, Devon 

Baldwin, H. R., M.D,, New Brunswick, New Jersey, United Statei of 

America 
Ball, J. A., M.B., Heaton-Norris, Stockport 
Bankart, James, M.B., 19, Southernhay, Eieter 
Banks, William A., M.D., Rockland, Mune, United States of America 
Barrett, A. E., 12, Ladbroke Grove, W. 
Barrett, J. W., Kings Lynn, Norfolk 
Barrett, 8. B. C, Kneller's Court, Fareham, Hampshire 
Barrow, F. E., Surgeon with Royal AitUlery, Tonngboo, Burmah, 

Madras Presidency 
Barrs, A. O., M.B., CM., General Infimury, Leeds 
Barton, J. Kinuton, 68, Gloucester Boad, Queen's Gate, S.W. 
Beale, £. Clifiord, M.B., B.A., 35, Upper Berkeley Street, Portman 

Square, W. 
Bealey, Adam, M.D., Oak Lee, Harrogate 
Btaney, James George, Collins Street, Melbourne, Anstntli* 



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viii List of Subscribers. 

B«ardaley, Amos, Bay VUta, GrBD^e-over-Sands, Lancaahire 

Seddard, James, M.B., Park Row, Nottingham 

B«eby, Walter T., M.D., Bromley, Kent 

"Berry, Heary Thomaa, 29, Amwell Street, Claremont Square, B.C. 

Bettany, 0. T., M.A., B.Sc, F.L.S., 2, Eckington Villas, Asbboarae 

Grove, East Dolwich 
B«™i, Bichard, New Bomney, Kent 
Biddle, H. C, Addison House, Edmonton, Middleaex 
Bird, Tom, M.A., 38, Brook Street, GrosTenor Square, W. 
Birdwood, B. A., B.A., The Infirmary, Gravesend 
Birkett, Edmund Lloyd, M.D., 48, Eussell Square, W.C. 
Birkett, John, 59, Green Street, GrosTenor Square, W. 
Bissbopp, James, Bedford Place, Tunbridge Wells 
B)aker, Nathaniel P., 29, Old Steyne, Brighton 
Blaker, Thomas F. I., Clarendon Lodge, Gotdstone ViUu, Cliftonville, 

Bnghton 
Blasson, Thomas, BiUingbo rough, near Folkingham, Lincolnshire 
Booth, Lionel, M.D., Oakfield House, Blackburn Bead, Accrington, 

Lancashire 
Boaworth, John Boutledge, Sutton, Surrey 
Bovil], Edward, M.B., CM., 32, James Street, Buckingham Gate, 

S.W. 
Bowen, A. L,, 5, Lewiaham Road, Blackheath, S.E. 
BowflD, Owen, Liandilo, South Walea 
Bowen-Jones, L. M., Gwarmacwydd, Llanfallteg, K. S. 0., South 

Walea 
Bruley, W. A., M.A., M.D„ 1 6, Orchard Street, Portman Square, W. 
Branfoot, Henry S., M.B. 
Brett, A. T., M.D., Watford, Hertfordshire 
Brett, J. T., Doncaster Road, Botherham, Yorkshire 
Bright, John M., M.D., The Glen, Forest Hill, S.E. 
Brixton Medical Book Society (per John J. Purnell, Esq., Woodland s, 

Streatham Hill, S.W.) 
Brogden, B. W., Guy's Hospital 
Brooks, A. D'O., Henley-on-Thamea 
Brooks, Brausby, Sonning, near Heading, Berks 
Brown, A. Gardiner, 9, St. Thomas's Street, S.E. 
Brown, Burton, M.D. (per F. G. Brown, Esq., 16, Finsbury Circua, 

E.C.) 
Brown, Cbaa. B., M.D., Aabford House, Hartington Place, Eaat- 

bourne 
Browne, George. 35, Montpelier Boad, Brighton 
Bryant, Thomas, 53, Upper Brook Street, W. 
Buchanan, Walter, 2, Gibraltar Place, Chatham, Kent 
Budd, Herbert G., College Gates, Worcester 
Bunting James, 1, York Villaa, West Green Boad, Tottenham 
Bordett, H. 0., 39, Gloucester Terrace, Begent's Park 
Burrell, Edwin, M.D., 20, Endsleigh Street, Tavistock Square, W.C. 
Burroughs, Thomas John, M.D., Crondall, Hampshire 
Burton, John M., Lee Park Lodge, Lee, S.E. 



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lAgt of Subscriberi, ii 

BnsheU, S. WooUon, M.D., Pekiu, Chioa (care of R. Mathewi, Biq.) 
Butler. William Harrii, 16, Thomas Street, 'Woolwich 
Bntton. Horace G., Southland Hoipita], Invercargill, New Zwdand 
(tnu? San Franciaco) 

Cann, Franda M., 6, Plantation Terrace, Davlieh, Deron 

Carey, Francis, M.D., Tilla Carey, Grange Eoad, QueraBCf 

Camelley, M., Guy's Hotpital 

Carr, T., Guy'a Hospital 

CKn6, Lonia C. A., 131, Camberwell Boad, S.B. 

Canington, R. E., M.D., 4, St. Thomas's Street, S.B. 

Carter, Thomu, Kichmond, Torkihire 

Cawley, Thomas, M.D. 

Ceely, J. H., Aylesbury, Bucks 

Champ, i. H., Guy's Hospitnl 

Cheese, James, Tredegar Place, Newport, Monmouthshire 

Chicken, Rupert C, 54, Forest Road, Nottinghsm 

Clarke, Henry, H.M. Prison, Wakefield, Yorkshire 

Cleveland, W. P., M.D., Stnsrt Vills, 199, Maida Vale, W. 

Clifton Medical Reading Society (per Messrs. Thomas Kerslake & Co., 

Booksellers, Bristol) 
Clover, J. T., 3, Cavendish Place, W. 
Clowes, Francia, Stalham, Norfolk 
Clowes, H. A., Guy's Hospital 
Clnno, T. R. H. 

Cock, Edward, Dean Street South, St. Thcmaa'a Street, S:E. 
Cock, Waiiams, 134, Queen's Road, Peckham, S.E. 
Coekell, Frederick Edgar, 144, Amhurst Road, Hackney, E, 
Cockell, Edgar, Hollv Lodge, Forest Road, Dalston, E. 
Cogan, Lee F., .'il. Sheep Street, Northampton 
Cole, R. M., Clarence Street, Gloucester 

Collet, Aug. H., B.A., South Lodge, Grafton Road, Worthing, Sussex 
Collins, H. W., Wrington, ueai Bristol 
CoUington, J. W., Kibworth, Leicestershire 
Colson, Edward, Indian Medical Service, Dhnlio, Bombay 
Cooke, James Wood, Barnstaple 
Cornwall, James, Fairford, Gloucestershire 
Couch, Thomas Quilter, Bodmin, Cornwall 
Conling, Henry, 42, Norfolk Square, Brighton 
Court, Josiafa, Slaveley, Chesterfield 

Creed, C. P., Rathkeale House, Girdlers Road, West Kensington, W. 
Cregeen, J. Nelson, 93, Upper Parliament Street, Liverpool 
Crew, John, High am- Ferrers, Northamptonshire 
Croft, Jobu, 61, Brook Street, Grosvenor Square, W. 
Crompton, Dickinson W., 17, Temple Row, Birmingliam 
Croasley, C, Scailcliffe House, New Walk, Leicester 
Cruiae, F. B., M.D., 3, Merrion Square West, Dublin 
CnnniDgham, John, M.6., Campbeltown, Argyleshire 
Cnolaban, H., M.D., 9, Grange Road, Bermondsey, S.E. 
Currie, 0. J., Guy's Hospital 



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X List of Subscriberi. 

Daglish, Richard Rothweil, Joy Cottage, New Romney, Kent 

Dnkin, W. R., Guy's Hospital 

Daldy, Frederick Samuel, 2, Manoi" Place, Horsham, Sussex 

Dalton, B. N., M.D., Selhurst Eoad. South Norwood, S.R. 

Daniell, George Williamaon, Blandford, Dorsetshire 

Dsvies, Ebenezer, Brunswick House, Swansea 

Davies-Colley, J. N. C, M.A., M.C., 36, Harley Street, W. 

Davis, G., 11, The Avenue, Blackheath, S.E. 

Dayy, Henry, M.B., 3-1, Southernhfly, Exeter 

Davy, Richard, 33, Welbeck Street, CsvendiBh Square, W. 

Debus, Henry, Ph.D., F.R.S,, Athenreum Club, Pall Mall, S.W. 

Denne, Henry, M.D., 8, Hagley Koad, Edgbaston, fiirmingliam 

Devon and Eieter Hospital Library (per James Bankart, E^q., M.B , 

19, Southernhay, Exeter) 
Dii, John, 25, Albion Street, Hull 
Dolman, A.H., \4, Wardwich Street, Derby 
Douglas, W. T. P., B.A., M.B., Newbury, Berks 
Downes, G. L., Guy's Hospital 
Dryland, W., Dulwich Common 
Duke, Edgar, 87, High Street, Clapham. 
Duke, Maurice S., 272, Kennington Park Road, S.E. 
Duran, Carlos, and Nunez, Dauiel, Costa Rica (care of Messrs. Le 

Lacheur and Son, 1 1 / and 1 18, Leaflenball Street, E.C.) 
Darham, Arthur E., 82, Brook Street, Grosvetior Square, W. 
Durham, Frederic, M.B., 38, Brook Street, Grosvenor Square, W 
Dntton, Edward O. 

Eager, Reginald, M.D., Northwooda Asylum, Frampton Cotterell, near 

Bristol 
Eaatet, George, M.B., 69, Connaught Street, Hyde Park Square, W. 

Eastes, Silvester, 19, London Street, Folkestone 

Easton Medical Book Cluli (per Dr. C. Mclutire, 311, Northampton 

Street, Easton, Pennsylvania, United States of America) 
Edwards, 0., Broad Street, Leominater, Herefordshire 
Elder, George, M.B., CM., 17, Regent Street, Nottingham 
Elphick, Edward, Tea Tree Gully, near Adelaide, South Australia 
Elphinatone, Bobert 
English, D.C., M.D., New Brunswick, Kew Jersey, United States of 

America 
Evans, Alfred H., Sutton Coldlield, Warwickshire 
P...-. .Tnhn HBnr,7 ^1 S.u,dy Road, Seaforth, Liverpool 

?. Load., 10, Mansfield Villas, Hampstead, 

del) Sussex 

laae, Cheetbam HiU, Manchester 

'illas. Ex mouth, Devon 

Bisey, Esq., Station Road, Bedhill, Surrey 

, Orosvenor Street, W. 

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List of Subteriberi. si 

Ftirdoth, Kchud, 3, InTcniMB Qtrdeoi, Campden Hill, Keniing- 

ton, W. 
Ptrr, George F., M.D., Slade Hoaw, KenningtoD Boad, 8.B. 
Fawsitt, Thomas, 5, George Street, Oldham 
Fer^sBon, James, M.D., Strathalbyn, South AnttraUa 
Fev, William, RamRey, Huntingdon 
Field, Ernest, M.D., CM., 12, Queen Square, Bath 
Pinch, Robert, M.D., Stainton Lodge, Blackheatb 
Forater, J. Cooper, 29, Upper GroaveDor Street, W. 
Forty, I). H., The Rectory, Wootton- under- Edge, Glonceatenliin 
Foster, O. H., M.A., M.B., Hitchin, Hertfordshire 
Fotherby, Henry I., M.D., 3, Finabury Sqnare, B.C. 
Fowler, Geo»e, 170, RenDiagtoa Park Road, S.£. 
Fowler, W., G^a HospiUl 

Frtocia, D. J. T., M.D., Cnmldgb, Gaildford, Sarrey 
Fry, J. F., Belvoir, St. Helen's Boad, Svantea, South Walea 
Faller, Thomas, M.D., LongcroftB, New Shorehaid, Sossex 

Gxlabin, A. L., M.A., M.D., 14, St. Thomaa'a Street, S.B. 

Oalton, John, M.D., Woodside, AnerleyRoad, Upper Norwood, S.E. 

Galton, E. H., Briztan Rise, Surrey, S.W. 

Gardner, J. T., Northfield House, Ilfncombe, Devon 

Garrard. W. A., Wellgate, Botherham, Yorkshire 

Oathergood, B. W., Terrington St. John, Lynn, Norfolk 

Golding-Bird, C. H., B.A., M.B., 13, St. Thomaa'a Street, S.B. 

Gooding, John C, MJ)., Alconbury, Berkeley Street, Cheltenham 

Goodhart, J. F., M.D., 27, Weymouth Street, Portland Place, W. 

Gorham, John, Tunbridge, Kent (through Bookseller) 

Goiae. H. W., Guy'a HoapiUl 

Gowing, Benjamin C, Atod Hoaae, Saiiiabury 

Goyder, Cavid, M.D., 86, Great Horton Road, Bradford, Yorkshire 

Graham, John. M.D., 29, Gloaceater Road, Regent's Park, N.W. 

Greenhow, £. Headlam, M.D., F.R.8., Cutle Lodge, Reigate 

Greenwood, E. C, Guy's Hospital 

Griffiths, Owen 

Gross, Charles, Newington Infirmary, Westmoreland Boad, Walworth, 

S.B. 
Grove, W. B., M.D., St. Ives, Hnntingdonshire 
Growse, J. L., Bildeston, Suffolk 
Growse, W., Gn/s Hospital 
GoU, Sir W. W., Bart, M.D., D.C.L., F.R.S., 74, Brook Street, 

GrosTenor Square, W. 
Gny, Th«mas, M.I>., 23, Aoriol Rosd, West Kensington, W. 
Gny's Hoapttfd Ubrary (Two Copies) 

Haberabon, S. 0., M.D., 70, Brook Street, Grosrenor Square, W. 

Hadeo, W. H., H.D., «6, HuUy Street, W. 

Hall, Junes Griffith, J.P., Swansea 

Hidla. Thomas Edward, 64, Tooley Street, S.E. 



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xii List of Sahscriber*. 

Hants Royal County Hospital, Wnchester 

Harding, C. F., M.D., Whittlesea, Cambridge 

HarrioaoD, Isaac, Castle Street, Reading 

Harris, Vincent D.. M.D., 23, Upper Berkeley Street, W. 

Harrison, A. J., M.B., Failsnd Lodge, Guthrie Road, CItftoa 

Hartley, W. Darley, 2, Fennistoae Street, Shepherd's Bush, W. 

Hartree, J. P., M.A., M.B., Strandtown, Belfnst 

Harvey, C. T., 50, Hoghton Street, Soiithport 

Hayward, John W., Whitetable, Kent 

Heddy, 'W'illiam Jackson, 92, Redcliffe Gardens, South Kensington, 

8.W. 
Hibberd, E., M.D., Campfield Lodge, Waltertoa Eoad, St. Peter's 

Park, W. 
Hicks, John Bnutton, M.D., F.R.8., 24, George Street, HanoYer 

Sqaare, W. 
Higgens, C, 3t^, Brook Street, Grosvenor Square, W. 
Higgina, Charles Hayea, M.D., Alfred House, Birkenhead, Cheshire 
Hills, A. Phillips, Carlton House, Bridge Road, Battersea Park, S.W. 
Hilla, William Charles, M.D., County Lunatic Asylum, Thorpe, Nor. 

wich 
Hindle, F. T., Aakem Hill, near Doncaster 
Hohson, J. M., M.B., Uplands, Seienoaks, Kent 
HodsoB, Frederic, Hornsea, Hull 
Holman, Constantine, M.D., J.P., Reignte, Surrey 
Holman, H. Martin, M.D., Huratpierpoiut, Sussex 
Hood, Donald W. Charles, M.B., 43, Green Street, Park Lane, W. 
Hood, Frank C. 

Horrocks, Peter, M.D., 29, Merrick Square, S.E. 
Houseman, John, M.D., 68, Jesmond Koad, Newcastle-upon-Tyne 
Howard, Dr., A7, Union Avenue, Montreal, Canada (per^ Messrs. 

Lindsay, Bristow, and Co., Bread Street, Cbeapside) 
Howell, J. B., Guy's Hospital 

Howell, T. A. I., The Old Vicarage, Wandsworth, S.W. 
Howse, H. Greenway, M.S., 10, St. Thomas's Street, Southwark 
Hudson, R. S., M.D., Redruth, Cornwall 

Hughes, Robert Harry, M.A., M.B , 12, Lockyer Street, Plymouth 
Hutchinson, V., M.D., The Elms, Bishop Auckland, Durham 

Ince, John, M.D. (per Messrs. Grindlay and Co.) 
Ingle, Robert N., M.C, 21, Regent Street, Cambridge 

Jackson, A. C, Csue Town, South Africa 
Jackson, Arthur, Wilkinson Street, Sheffield ' 
Jackson, James, M.D., Mount Gambier Hospital, South Australia 
Jackson, P. J., Surrey Dispensary, 6, Great Dover Street, S.E. 
Jaeobson, W. H. A., B.A., M.B., 41, Finsbury Square, EC. 
Jailsnd, W. H., St. Leonard's House, Museum Street, York 
James, Philip, Pandy House, Llwyn-y-pia, Pout-y-Pridd, Glamorgan, 
shire 



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ZAsi of Subtcribert. xiii 

JamcB, W. C, M.T).. 1 1, MHloei RowJ, Cromwell Ro»d, Kemington, W. 

John, Wm., Court House, HftTerfordwe»t, Pembrokeahire 

Johnaon, David, M.D., 10, Penywern Road, South Keniingtoo, B.W. 

Johnson, W. P., Charing, near Aahford, Kent 

JoDes, George, B.A., FTsmlinghsm, Suffolk 

Jonee, 0. H. West, Gckiugtoii, Cheaterfield, Derbyahira 

Jonea, J. Edwardi, M.D., Brjnffyuon, Dolgelly, North Walei 

Jonea, John Thomas, 179, Brixton Road, S.W., and LUnfjtlin, 

Montgomeryahire 
Jonra, Morria, Aberyatwith, Cardiganahire 
Jonea, Thomaa, M.B., Royal Infirmary, Mancheater 
Joyce, Thomas, 2, Pembridge Oardeua, Bayswater, W. 
Judaon, T. R., West Derby, Lirerpool 

Keep, Cbarlea H., Ouy'e Hospital 

Kellock, W. B., Stamford Hill, Stoke Newiogton, N. 

Eelaey, A., Station Road, Redhill, Surrey 

Kelso Diapeniary, Roxburghshire (per Dr. Thomaa Hamilton) 

Kendall, Waiter B., Bishopton, Stratrord-on-ATon 

Kent, Thomas J., 60, St. James's Street, S.W. 

Ker, Hugh Richard, Roxburghe Houae, Old Hill, Dudley, StafforJahire 

Kidd, W. A.. M.D., B.S., 12, Montpelier Row, Blackheath, 8.B. 

Kingaford, Edward, Sanbury, Middlesex 

Lacey, John, 23, Trioity Street, Southwark, S.E. 

Lacey, T. W., 196, Burrage Road, Plumatead 

Lacy, A. 6., The Cottage, Sunninghill, Staines. Middlesex 

Lamb, Joseph, IS, Price Street, Birkenhead 

Lamb, William Henry, M.B., 46, Kensington Park Gardens, W. 

Laacereaux, E., M.D., 3, Rue St. Arnaud, Paria 

L&uadowD, F. P., 19, White Ladiea' Road, Clifton, Bristol 

Larkin, F. G., 44, Trinity Square, S.E. 

Lee, C. Q., 84, Bedford Street South, LiTerpool 

Leeda School of Medicine Library (perDr. Allbatt, School of Medicine, 

Leeda) 
Lewis, Cbarlea, 67, Sandgate Road, Folkeatone 
Lipscomb, John Thomas N., M.D., St. Albana, Hertfordahire 
Liater, J. H., Guy'a Hospital 

Love, Angustue E. B., Richmond Villa, Bonmemonth 
Lucas, E. Clement, B.S., 18, Finabury Square, B.C. 
Lucas, Herbert, Huntingdon 

Lucey, William Cubitt, M.D., Cranhnry Place, Southampton 
Lund, Edward, 22, St. John Street, MancheaUr 
Luah, Wm. George Vawdrey, M.D., 12, Frederick Place, Weymouth 

Hacdonald, J. A., M.D., Wobum, Bedfordshire 

McKay, W. W.,M.D.j Main Street, Boise City, Idaho Territory, United 

Statca of America 
Mackem, George, M.D., Guy's Hospital 
Mackie, J., M.D., Cupar, Fifo 



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xir lAtt of Su^acribert. 

MaeoDchf, John K., M.B,, Inflnnarj Haase, Downpatriclc 

M»dge, Henry, M.D., 4, Upper Wimpole Street, W. 

Mahomed, V. A., M.D., 12, St. Thomu'i Street, S.E. 

Makene, J., M.B, 43, Trioity Square, S.E. 

Mftllam. G. B., 28, Cadt^an Terrace, South Hackney, E. 

Mallatn, W. P., 6, Boicombe Terrace, Uzbridge Road, Shepherd'a 
Baah, W. 

Manby, Pxederic, East Bndham, Swaffham, Norfolk 

Manby, Frederic E., 10, King Street, Woherhamplon 

Manchester Boyal lufirmary (per The Secretary). 

Marshall, Edward, Mitcham, Surrey 

Martin, A. fiae. The Precincts, Bochester, Kent 

Martin, F., M.D., The Priory, Lower Sydenham, S.B. 

Martin, Joseph Cooper, 2, West Hill, Dartford, Kent 

Masters, J. A., The Mount, Hednesford, Staffordshire 

Mathews, Bohert, Bickley, Kent 

Mickley, Arthur Q., M.B., St. Miry'a Infirmary, St. John's Road, 
Upper Hollow ay, N. 

Mickley, George, M.C., MB., St. Lnke's Hoaintal, Old Street, B.C. 

Miiward, James, 27, Charles Street, Cardiff 

Montefiore, Nathaniel, 18, Portman Square, W. 

Moon, Henry, 26, Finsbury Square, E.C. 

Moon, B. H., Fern Lodge, Lower Norwood, Surrey 

Moore, J„ M.D., Toronto Villa, Baiham, S.W. 

Morgan, David C., Guy's Hospital 

Moi^an, John, Pontrhyd-y-groes, near Aberystwith . 

Morison, Joshua VI., Hamilton Terrace, Pembroke, South Wales 

Morley, Edward S., M.D., 16, Bichmond Terrace, Blackbnm 

Hurley, J. L. CoUison, M.D.. 124, Edith Boad, West Kensing- 
ton, W. 

Morris, Henry, M.A., M.B., 2, Mansfield Street, Portland Place, W. 

Morris, Johu, 30, Dorset Gardens, Brighton 

Morae, R. E. B., Eton House, Oriel Terrace, Chelteoham 

Morse, T. H., Guy's Hospital 

Mozon, H. J., Gay's Hospital 

Mozon, Walter, MD., 6, Finsbury Circus, B.C. 

Hunden, Charles, Ilminster, Somerset 

Muriel, Charles Brans, 71, St. Giles's Street, Norwich 

Muriel, George John, 14, Scotch Street, Whitehaven 

Murphy, S. F., 158, Camden Road, N.W. 

Naaon, John Jamea, M.B., 8tratford-on-Avon 

Newman, Alfred K., M.B., The Club, Wellington, Nev Saaluid 

Newman, J. J., 6, Matlock Terrace, Torquay 

Niabett, Bobert Innes, The Eagles, Overcliff, Graveaend 

Northampton General Infirmary Library (per the House Surgeon) 

Now^ B. B., Henry Square, Asbton-nnder-Lyne 

Nnnn, Geoi^e Bichard, Lyndhurat, Hampshire 

NuDoeiey, John, M.B., 22, Park Place. Leeda 



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£A»t of Sub»eriber». xv 

O'Grady, E.S.. M.B., CM,, !05, Stephen's Green Sontb, Dnblin 

Oldham, Henry, M.D., 4, Cavendish Place, W. 

Oldham, James, 53, Norfolk Square, Brixton 

Oweu.Jonei, Percy, 662, W. Tan Buren Street, Chicago, IDinois, 

United Statee of America. 
Ozley, W., 1, South Terrace, Botherham, Torkahire 

PaddoD, Oeoi^e, Laurel Home, 83, High Street, Pntney 

Padley, George, Northampton Lodge, Swansea 

Palfrey, JameB, M.D., 29, Brook Street, Grosrenor Square, W. 

Palmer, W.- G., Loughborough, Leicestershire 

Paramore, Bichard, 18, Hunter Street, Brunswick Square, W.C. 

Parker, Bobert W., 8, Old Cavendisb Street, Cavendish Square, W. 

Parkinson, 0. H. W., Wimbome-Minster, Dorset 

Paul, Frank T., 57, Rodney Street, Liverpool 

Pavy, F. W., M.D.. F.B.8., 35, GrosTenor Street, W. 

Payne, Arthur J., M.D., Surgeon -Major, Bengal Medical Serrice (ppp 

Meaars. Lewis & Co., Qower Street) 
Pearae, E. Saiuthill, 3, Albion Street, Brierley Hill, Staffordshire 
Peat, Thomas, Manniugtree, Essex 

Pegge, Charles, Vernon House Asylum, Britonferry, near Neath 
Perkins, Charles E. S., M.B., 2, Kirkdale, Sydenham, 8.E. 
Perkins, G, C. S., Sydney Villa, Eimouth, Devon 
Perks, R. H., Guy's Hoapital 
Phelpa, W., Freshwater, Isle of Wight 
PhilUpps, W. A., Guy's Hospital 
Phillips, Richard, 27, Leinster Square, Bayswater, W, 
Pilcber, W. J., High Street, Boston, Lincolnshire 
Pilkington, F. S., Guy's Hospital 
Pilkington, F. W., Guy's Hospital 
Pilkington, Qeorge, Yarm-on-Tees, Yorkshire 
Bnching, Charles J. W., 6, The Terrace, Grareaend 
Plimmer, H. Q., Guy'a Hospital 
Pbmley, John Fred., M.D„ 9, Weat Boro,' Maidatone 
Poland, John, Gaye Hospital 
Portman Medical Book Club (per E. Oweo, Esq., 49, Seymour Street, 

Portmsn Square, W.) 
Prall, Samuel, M.D., Weat Mailing, Kent 

Prance, R. R., M.D., Rookeslea, Greenhill Road, Hampstead, N.W. 
Prendei^ast, J. J., Guy's Hospital 
Preston Medical Society (per J. E. Garner, Esq,, 18, Winckley 

Square, Preston, Lajicaahire) 
Pardon, T. H., M.B., S, Wellington Place, Belfast 
Purres, Laidlaw, 6, Stratford Place, Oifon! Street, W. 
Puiey, Chauncy, 71, Rodney Street, Liverpool 
Pye-Smith, E., St. Catharine's Lodge, Sevenoaka, Kent 
Pye-Smith. Philip H., M.D., 56, Harley Street, W. 
Pye-Smith, R. J., 7, Surrey Street, Sheffield 

Radford, T., M.D., Moor-Field, Higher Broughton, Mancheater 

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xvi List of Svbtcribert. 

Ralcp, B. N., M.B., Gny's Hoipit&l 

Rsmskill, Joaiab, 29, Meadow Lftne, Leeds 

RamBlciU, J. 8., M.D., 5, St. Helen's Place, BishopBgate, E.G. 

Entid, John, Walton House, Grove Hill, Dulwich, S.E. 

Ray, Edward Eeynolds, North Dulwich. S.E. 

Rees, G. Owen, M.D., F.E.S., 26, Albemarle Street, W. 

Beiaold, A. W., M.A., Boyal Naval College, Greenwich, 8.B. 

Rendle, Richard, Treverbyn, Dartmouth Park, Forest Hill, S.E. 

Reynolds, L. W., High Wycombe, Backs 

Reynolda, "W. P., Stamford Hill, N. 

Bichardaon, H. £., Guy's Hospital 

Richardson, T. A., General Hospital, Croydon 

Richmond Hospital Library, Dnblin (per Dr. Gordon) 

Roberts, Alfred, 45, Philip Street, Sydney, New South Wales 

Roberta, Bransby, M.D., Badlesmere House, Eastbourne, Sussex 

Roberts, J. H., Hill Crest, Greenhill Boad, Hampstead, N.W. 

Rogers, Robert J., 40, Cannon Place, Brighton 

Romano, F. W. R., Pelotas, Rio Grand do Sul, Brazil 

Rooke, Thomas Morley, M.D., 7, Bays Hill Villas, Cheltenham 

Roots, W. Henry, Kingston- on -Tharoes, Surrey 

Roper, A. G., 57, North End, Croydon 

Roper, Arthur, 17, GranTiUe Park, Blackbeath 

Roper, £„ Higbfield House, Sbeppertoo, Middlesex 

RoiB, John Harria, M.D., CM., 8, St. George's Place, Brighton 

Robs, Richard, M.D., 7, Wellington Place, Belfast 

Salter, S. J. A., M.B., F.R.S., 49, Devonshire Street, Portland 

Place, W. 
Salzmaan, Frederick William, 18, Montpellier Boad, Brighton 
Sanders, i. W., Guy's Hospital 
Sangster, Charles, 146, Lambeth Road, S.E. 
Savage, G. H., M.D., Belhlem Royal Hospital, S.E. 
Scott, Francis, Bridport, Dorsetshire 
Scott, R. J. H., 2, Terrace Walk, Bath 
Sells, C. J., High Street, Guildford 

Seymour, Almeric, M.D., 18, Montpellier Place, Brighton 
Sharp, John Adolphus, 6), Osmaston Street, Derby 
Shaw, C. T. K., 33, Warrior Square, St. Leonard 'a- on- Sea 
Shelswell, 0. B., Guy's Hospital 
Shepherd, A. B., M.A., M.D., 17, Great Cnmberlaad Place, Hyda 

Park, W. (for the Library of the University of Freiburg, in Baden) 
Sheppard, G, A., Foregate Street, Worcester 
Sfaipiuan, George Wm., Grantham, Lincolashire 
Sigwr, G«o. A., M.D., Brownaville, Union County, Indiana, United 

States of America. 
Simon, R. M., B.A., M.B., 27, Newliall Street, Birmingham 
Skinner, David 8., Lyme Regis, Dorsetshire 
Skinner, William A., 45, Lower Belgrave Street, S.W. 
Smith, J. S., Guy's Hospital 
Smith, James William, 13, Hall Gate, Doucastcr 



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lilt of Subteiiberim xm 

Spender, J. K., M.D, 17, Circus. Bath 

Spry, Q. Fredeiick Hume, M.D., Sod Life Gunrda, Annv and Navy 

Clab, FaU Mall, S.'W^. 
Spni^in, Herbert B., 45, AbiDgtoD Street, NorthamptoD 
Spor^n, Thomaa, Mareton, Ongar, Essex 
Stamper, James F., M.D., Pembroke Dock, South Wales 
Starimg, W. B., Ony's Hospital 
Stedman, John B., Godalming, Surrey 
Steele, J. C, M.D., Guy's Hoapital 
Steele, Kichard, 8, Yanbn^b Park East, Blackbeath 
Stephens, Thomas Palmer, Westboame, Sussex 
SteveoBou, Tbomu, M.D., Sandhurst Lodge, Gresbam Boad, Brixton 

S.W. 
Stilwell, Sobert B., M.D., Beckenham, Kent 
Stocker, John Sberwood, M.D., 2, Sfontagu Square, W. 
Stoke Nevington, Clapton and Hackney Medical Book Society (per 

Bobert HarriE, Esq., M.B., 57, Damley fioad, Hackney, E.) 
Stokoe, P.H., B.A., M.D., The Chestnuts, Beddington, Croydon 
Stotbard, W. J., Denmark HUl, S.E. 
Stnart, E. O., Guy's Hospital 
Stnige, H. H., Gny's Hospital 

Satton, Frederick, Willingham-by-Sto», Gainsboro', Lincolnahire 
Sutton, Henry G., M.B., 9, Finsbnry Sqnare, E.C. 
Symonds, Charters Jamea, M.S., 16, St. Thomas's Street, S.E. 

Taylor, Frederick, M.D. , U, St. Thomas's Street, S.E. 

Taylor, R. Stanley, M.B., 7, Friar Gate, Derby 

Taylor, Thomas, Sutton Coldfleld, Warwickshire 

Ticehurst, C. S., Fetertfield, Hants 

Ticehnrst, Augustus E., Silcbester House, PeTcnsey Road, St. 

Xiconards'on-Sea 
Todd, J., 7, Thumham Street, Lancaster 
Tovnaend, T. S., 6S, Queen's Gate, South KensiogtoQ, S.W. 
Treror, E. T., Gny's Hoapital 

Tnchmann, M., M.D., 148, Adelaide Road, Haverstock Hill, N.W. 
Tamer, A. M., Glouceater 
Turner, H. Q., Holmvood, Bournemouth 
Tyson W. J., H.D., 89, Sandgate Road, Folkestone 

Uhthoff, J. C, M.D., 46, Western Road, More, Brighton 
Underbill, W. Lees, Tipton Green, Staffordshire 

Valentine, Edmund William, Somerton, Somersetshire 

Tawdrey, George 

Teasey, Henry, Woburn, Bedfordshire 

Tewy, T. A., M.B., West View, Rosstreror, Ireland 

Wacber, Prank, Kingsbridge, Canterbury 

Waddy, H. E., 30, Clarence Street, Gloucester 

Wunewright, Robert S,, M.B., Belmont Villa, Lee, Kent, S.E. 



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xfiii lilt of Subtcribtrt. 

Wales, T. Gmrnejs, Downham Market. Norfolk 

Wallace, Frederick, 243, Hacknty Road, E. 

Wallace, Richard U., M.B., 1S6, Amhurst Road, Hackney, E. 

Waller, W, A. E., 46, Albert Street, Bngby 

Wallis, W., Jan., Groombridge, Tunbridge Wella 

Wanhbonm, Buchanan, M.D., Oloacester 

Watkina, W., Georgetown, Demenu-a, British Guiana 

Warner, P., Ony'a Hospital 

Wataon, W., Qaf* Hospital 

Weaver, F. P., M.D., Frodaham, Cheshire 

Weber, Hermann, M.D., 10, GrosveDor Street, W. 

Weir, Patrick A., M.A., M.B., CM., Surgeon Bengal Army (per 

Meaara. King, Hamiltoa, and Co., 7, Hare Street, CalcntUt) 
Weston, E. F., Chetwynd Home, Stafford 
Wheeler, D. M. B., Chelmsford 
White, B. P., M.D., Pump Street, Londonderry 
White, Charle», Warrington 
White, B. W., Guy"a Hospital 
White, W. Hale, M.D., Park Hill, Carshalion 
Wilkin, J. F., M.D., M.C., Holmhurst, Beckeaham, Keut 
WiUca, Samuel, M.D.,' F.B.S., 72, GrosTenor Street, Grosvenor 

Square. W. 
Willan, G. T., Melton Mowbray, Leicestershire 
WilletC, Edmnnd S., M.D., Wyke House, Syon Hill, Isleworth 
Wiltiama, W. R., M.D., Commission on Lunacy Office, 19, Whitehall 

PUce, S.W. 
Williamaon, N., H.O., New Bninawick, New Jersey, United States of 

America 
Wilton, }., Chalk-pit House, Sutton, Sarrvy 

Wise, William C, M.D., Gothic Villa, Burrage Road, Pliimstead, Kent 
Wiseman, John Greaves, Denrden Street, Ossett, Wakelield 
Wolcott, Samuel G., Uttca, New York, I'nited States of America 
Wolatenholme, H. J., High Cross, Tottenham 
Wood, P. M., Guy's Hospital 
Wordley, A. W., Guy's Hospital 
Workman, John W., Russell Street, Reading 
Wright, Charle* J., 4, Park Square, Leeds 
Wri^t, 6. A., B.A., M.B., 24, Ducie Street, Manchester 

Tork Medical Society (care of Fred. Sbann, Esq., 3, The Creacent, 
York) 



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In ExcHANae. 
The St. Butholomew's Hoapitd ReporK. 
The St. George's Hoapital BeporU. 

The LiTerpool and Muacheiter Medical sod Surgical Reports. 
The St. ThoDuia'a Hospital Reports. 
The Pharmacentical Jonmal. 

The TnuuactioDs of the Obetetrical Society of LoDdon. 
American Journal of the Medical Sciences (care of Heisrs, Trubner 

and Co., Lndgate Hill, E.G.). 
Annales de Dermatologie et de Syphiligraphie (care of M. le Dr. Ernest 

Besnier, 87, Rne Neare des Matbanns, Paris). 
Jonmal de Therepentiqne (care of M. le Br, Labb^, 10, Rue de 

Tnrbigo, Paris). 
Revue dee Sciences Medicales en France, et h I'^tnmger (care of 

H, le Dr. Hayem, 17, Rue du Sommerard, Paris). 
VcrhandluDeen der Berliner mediciniacben Gesellscbaft (care of Herr 

A. Falk, Library Gntmann, Friedrichs Strasse 97, Berlin). 
Centralblatt fur Cbirui^ (care of Messrs, Breitkopf uod Hartel, 

Leipzig). 
Beitrage inr Medizinal-Sutistik (care of Dr. W. Zuelzer, Wtlhebn 

StrasM 66, Berlin, W.). 
Upsala l^akareforeningB Forhandlingar (per Prof. Hedeniua, Biblio- 

tb^que de la Soci^te des M^dedna, Upaal, Sn&de). 
Le Progrfei Medical (per Dr. Bourueville, Rue des Scoles 6, Psria). 
Chicago Medical Jonmal and Examiner (per Dr. W. H. Byford, care 

of Messrs. W. B. Keen, Cooke, & Co,, 113 and 115, StaU Street, 

Chicago, United Slates of America). 
Pioceedinga of the Medical Society for tbe County of Einga (Society 

Rooms, Everett HaU, 396, Falton Street, Brooklyn, New York, 

U. S. America). 
Transactions of the American Medical Association (per Mesars. 

Churchill). 
Transactions of the American Oyneecologicat Society, Clarendon 

Street, Boston, Mass. (per Messrs, Churchill). 
Library of Surgeon-General's OfBce, U.S. Army, Wasbington, D.C. 

(per Mr. B. F, Stevens, U.S. Goveroment Despatch Agency, 

4, Trafalgar Square, London, W,C.) 
Annali Universal! di Mcdidna e Chimrgia (per Dr. Corradi, Pavia, 

North Italy). 
Transactions of tbe Brooklyn Anatomical and Surgical Society, 28, 

Hadison Street, Brooklyn, New York, U.S.A. 



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D„t,M,Google 



ON PTJBPrRA HiBMOEEHAGICA, 



xcooiaumsa 



THE GROWTH OF MULTIPLE SARCOMATA. 



Br C. HILTON FAGGE, M.D. 



Ahono the various caases of a purpura attended with htemor' 
rhage from mucous Burfaces — the affection commonly known 
on the Continent as the Morbus maculosus Werlhofii, in 
memory of Werlbof, who was physician to the King of Great 
Britain in Hanover in the middle of the last century- — there is 
one which aeema to have been left almost unmentioned by 
writers. It is the rapid development of sarcomatous growths 
in various oigans, or throughout the body generally. Several 
c:ases in point have occurred at the hospital within the last 
twenty years, and I believe that they are well worthy of being 
collected together and placed on record; and the more so, as 
tbey have been characterised by some other symptoms, the 
recognition of which might probably render a diagnosis of the 
real nature of such an affection more easy in the future than 
it has been in the past. 



Casb l.-^Purpura hemorrhagica, preceded by symptoma as of 
rheumatism ; tarcomaious tumours of skin, kidneys, and 
pericardium, secondary to a latent sarcoma of the ileum. 
(From the Keport of Mr. H. H. Stobob.) 
R. B — , set. 25, was admitted into Guy's Hospital, on July 
vol.. XJCV. 1 



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2 On Purpura Hamorrhagtca, accompanying 

28th, 1879, under Dr. Pye-Smith. He was a laboaring 
engineer, married, but without children. His father, he 
thought, had died of rheumatic fever. 

On Whit Monday (June 2nd) he got wet through. From that 
time be complained of occasional pains in the chest, over the 
oater side of the hips, and over the back of the left shoulder, 
bot they were not bad enough to compel him to give up work. 

On July 19th, however, he felt, on rising in the moming, 
severe pains in both shoulders and in both hips. He went to 
work, but came home at midday, and went to bed. The parts 
first attacked remained painful up to the time of his admission ; 
but, in addition, he had pain between the shoulders, and stiff- 
ness and pain in the right side of the neck. During mastica- 
tion there was pain over the rami of the jaws. Both knees 
became painful, but not swollen. 

On the 23rd the left eye watered, and became almost closed 
by swelling J the right eye also ached, and was sensitive to 
light. He sweated profusely day and night, so that bis shirts 
were " wringing wet." He felt hot, and " got out of bed for 
coolness." He had pain all through bis head, both front and 
back ; he was also giddy. He was able to walk for about six 
minutes on his way to the hospital. 

He appeared pale, languid, and ill, though fairly nourished. 
In addition to the pains in the parts already mentioned there 
were three very tender spots on the chest, one to the left of 
the sternum, another below the right nipple, the third near 
the inner end of the left clavicle. The slightest pressure over 
the left iliac crest caiised pain, which went half way down the 
thigh. There was no pain on pressing the hips laterally, nor 
on pushing upwards the soles of the feet. Scarcely any pain 
in the right hip and knee was caused by free movements of the 
limb, but over the anterior half of the right iliac crest there 
was great tenderness. There was also much pain round the 
right groin and in the tuber ischii. The upper limbs could be 
moved pretty freely, but raising the arms upwards or across 
the chest gave pain, especially on the right side. 

The skill was hot and moist; there was an unpleasant sour 
smell, especially when the clothes were raised. The appetite 
was very bad, but there was much thirst. The tongue was 
moist, pale^ and flabby. 

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the Growth of Multiple Sarcomata. 3 

There was some dnlness over the bases of both lungs, and at 
the right base the respiratory murmur was deficient. Kesp. 
32; temp. 102°j the urine, of sp. gr. 1026, was acid, without 
sediment. The heart sounds were healthy. The heart's apes 
was slightly outside the nipple. 

It was supposed that he was in the later stage of an attack 
of rheumatic fever; and on the 30th a systolic apex murmur 
was discovered when he sat up. 

On the 29th it is noted that he was sweating profusely, espe- 
cially over the head. At 6 p.m. the temperature was 102*2°; 
the pulse was 96. He was lying with his knees flexed and 
raised, as he found that this gave him most relief. At 9 a.m. 
the sweating was most profuse ; temp. 102*3°; pulse 96. 

30th. — He only dozed one or twice in the night. Temp. 
102'^ ; pulse 100. Fain chiedy at vertex of head and in left 
tuber ischii. Urine 1028, not clear, two pints six ounces iq 
twenty-four hours. 

or the further progress of the case there are unfortunately 
no detailed notes. But it is reported that he went on well 
nntil August 9th, when a purpuric rash came out on the chest 
and on the abdomen. He also had hiematuria. His eyelids 
and his scrotum became greatly swollen. His conjunctivse 
were ecchymosed. 

Some of the purpuric spots were noticed to be raised, and it 
was thought that they were inflamed and tending to suppurate 
or to form small furunculi. 

He rapidly became worse, and died on August 14th at 
9.55 p.m. 

I made an autopsy on the 15th, sixteen hours and a half 
after death. Decomposition was already rapidly advancing, 
the scrotum, the thighs, and the upper arms being emphyse- 
matous, 80 that air escaped from them when incised. The 
scattered spots of purpura still remained visible. They were 
seated chiefly on the side of the chest and abdomen, and about 
the groins. Some of them had the ordinary appearance, being 
flat, and red or purple in colour ; but others were distinctly 
raised, forming indurated purple nodules ; and yet others had a 
central pale elevation with a narrow ring of purple discoloration 
round it. They were all small, &om half a centimetre to a 
centimetre in diameter. When cut into they looktd esact^ as 



i On Purpura Hmnorrhagica, accompanying 

if they consisted of slightly svollea granular masses of adipose 
tissue, or were minute lymphatic glands, grey and flesliy. It 
Tas not until I had examined the viscera that I perceived 
them to be small growths, although the idea of a neoplasm had 
occurred to me as a possible solution of the case before I 
opened the body, ^hen I merely looked at the cutaneous afTec- 
tion. The microscope subsequently showed that the Dainnte 
round and irregular cells which made up the nodules had a 
curious tendency to infiltrate the small lobules of fat, the 
adipose vssicles being separated from one another, and enclosed 
each in a kind of capsule of new growth. 

The lungs were healthy, but the anterior edge of the left pleura 
was slightly ecchymosed. The pericardium was extremely ecchy- 
mosed, and on its visceral layer there were some flat, vhite, 
milky-looking spots and patches of peculiar appearance, and 
probably early nodules of the new growth. The heart was very 
soft and flabby. 

The liver and the spleen were healthy. The kidneys weighed 
12^ oz. together. Each of them contained many white or 
pinkish, succulent-looking, sarcomatous nodules. Many were 
very ill defined, and several of them in one kidney appeared to 
involve the pelvis of the organ. The bladder contained bloody 
urine. 

So far no lesion had been discovered which could be regarded 
as the primary starting-poiut of sarcomatous infection. At 
length, however, it was found that the last two inches of the 
ileum, including the ilco-ciecal valve, were greatly thickened, 
forming a massive tumour. This consisted of a fine homogeneous 
yellow material, yielding no juice on section. All the coats 
were infiltrated, the mucous membrane being thrown into smooth 
undulating elevations. The muscular coat was in part visible as 
a grey swollen line. 

The growth everywhere consisted of small round or irregular 
cells, very thickly crowded together. In the intestine they 
were supported by a considerable quantity of well-develops 
fibrous tissue, 

C&SB 2, — Rheumatoid symptoms lasting a month; purpura, 
/uimaturia, epistazis, bleeding from gums, fatal in $even 

D,o-z.,-,„Gooj^lc 



the Growth of Mvlliple Sarcomata. 5 

days from the commencement; sarcoma of veaicula »emi- 
nalia, neck of bladder, kidneys, omental glands. 

(From the Beport of Mr. Bobbbt J. Wjjnbwbiout.) 

P. J. A — , »t. 38, was admitted, under Dr. Moxon, into Guy'a 
Hospital, on May 9th, 1877. He was a cabdriver, and liad 
always been a strong man up to five weeks before his admission. 
His mother died of haemorrhage during a confinement. His 
father iraa alive and healthy. Six brothers and one sister were 
alive and well ; none had shown a tendency to haemorrhage. 
He had been married fourteen years, and had four children 
living, two others having died of croup. About fourteen years 
back he had had gonorrb(ea, which was not followed by stric- 
ture. He had never bad gout nor rheumatic fever. Since an 
attack of measles he had been deaf, and had had a discharge 
from the right ear. His nose had bled sometimes, but very 
seldom, and never to any extent. He had always had plenty of 
green vegetables, fruit, and fresh meat. 

Fire weeka back he believes that he caught cold from sitting 
on a vet seat and being exposed to draughts. He sufiered from 
pains in the hack, legs, arms, and chest, chiefly in the joints; 
the pains were felt first in one joint, then in another. His 
water was high coloured and became thick on standing; he 
sometimes passed red gravel, which gave him pain. At night 
he was restless and hot and sweated profusely, the sweat having 
a very sour smell. 

He was, however, able to do his usual work until six days 
before faia admiasiou, except at one time, when he remained in- 
dooiB for a few days but not in bed. But on May 3rd he sent 
for a medical man. The following night, while in bed, be was 
attacked with severe pain, which lasted for several hours, in the 
pnbea and round to the back. He applied a mustard plaster, 
and took some pepper in water ; violent retching and vomiting 
set in. Next morning he noticed, for the first time, purpuric 
spots on the neck, groins, and legs ; and when he passed water, 
which he did with difficulty, there was blood in it, 

After this he remained almost constantly in bed. His water 
always contained blood, and sometimes looked like pure blood. 
He had much difficulty and pain in voiding it, and sometimes 
passed clots. There ulsowere uric acid crystals. On May 5th 

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6 On Purpura Hamorrhagtca, accon^anying 

lie liad profuse eptBtaxis for about an hour ; he thinks he lost 
a pint and a Half of blood. His gums have been sore, and blood 
has been continually escaping from them into his mouth. 

The medical man who bad attended him confirmed this report, 
and added that his temperature had ranged at about 100^ and 
upwards. 

He was a fairly-nouriBhed man, much blanched, and very 
weak. His pupils were slightly dilated, and his eyes so sensitive 
to light that he was continually closing them. His mind was 
perfectly clear. There were numerous petechiee on both legs 
and feet, on the arms (especially at the elbows), and over the 
front of the neck ; and there were a few on the chest. The 
tongue was clean and healthy>lookiQg. The heart-sounds were 
faintly audible; the impulse was imperceptible. The lungs 
appeared to be healthy, but it was not possible to examine the 
back as his nose began to bleed. The liver and the spleen seemed 
to be of normal size. The urine was of sp. gr. 1036, dark purple, 
very thick, not coagulating spontaneously, but taming nearly 
solid when boiled. The microscope showed in it an immense 
number of red discs, some leucocytes, no casts. There was slight 
tenderness over the bladder, not elsewhere in the abdomen. 

At I p.m. the temperature was 103°, the pnl8e^l60, the respi- 
rations S6. 

The fpistaxis continued from 12.15 p.m. all the afternoon, 
with a few short intermissions ; every now and then he would 
spit large clots from the back of the mouth. The blood did not 
come in large quaotities at once, but trickled out of the nose 
down on the face, and backwards into the throat. He was 
obliged to make water rather frequently j it gave him some pain, 
and he had to wait for some time before any passed ; the urine 
looked like pure blood, it contained no clots. At 4.45 p.m. the 
temperature was 101'6°, the pulse 136, very soft aod compres- 
sible, respirations 25. There was a cold clammy sweat over 
the skin. He was able to answer qnestions without difficulty. 

The diagnosis was " purpura hsemorrhagica," He was 
ordered to take Acid. Gallic, gr. xx, Tr. Opii Hlxv, Syrup. 
Sirapl. 3J, Succ. Limon. 5ss, Aq. ad 3j statim, post boras trea, 
postea omni 6t& horfl. For diet he was to have milk, eggs 
and fiuid meat ; but he took only iced milk, altogether about 
two pints and a half. 



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the Growth of Multiple Sarcomata. 7 

Duriog the night the bleeding bom the nose still continued, 
hnt in small quantity ; he spat from the mouth several large 
dots. At 9 a.m. on May 10th he died. Before death his 
breathing became extremely sIot and laboured. Hia mind 
seemed clear, bnt he was unable to speak. The pnpils were 
moderately contracted. There was no convnlsion. 

An autopsy was made the same day by Dr. Ooodbart. 

The body was spare ; numerous small petechise were risible 
on the limbs and trunk. 

The chief seat of disease lay in the urinary organs. The 
kidneys were large, each weighing about 8 oz. They were pale 
and mottled on the surface, and they showed a number of 
rounded tumours, varying in size from mere dots up to one 
centimetre in diameter, white, elastic, almost jnieeless. The 
lai^r of these tumours extended almost through the whole 
thickness of the cortei, their margins were tolerably well deGned^ 
bat they gradually merged into the kidney texture, as if 
iofiltrating it. Many of them were ecchymoaed in the centre. 
The pelves of the kidneys were healthy, except that on one side 
there was a considerable extravasation of blood beneath the 
mncous membrane. 

The ureters were healthy ; the right one contained some 
milky fluid, which, on examination, showed epithelioid cells. 
The bladder was distended, but its lining was normal, except 
that it was slightly ecchymosed. The vern-montanum and the 
lining of the prostatic urethra had a peculiar white rugose 
appearance, and their submucous tissue was much thickened, 
and evidently infiltrated by a growth. The prostate itself did 
not appear to be much diseased, but the right vesicula seminalis 
and the vas deferens were converted into a large mass of 
white firm growth, with their channels still persisting in its 
centre. The thickening of the vas deferens continued for 
some distance along it. The left vesicula was a little thickened, 
and was probably in an early stage of the disease. The testes 
were healthy. 

It thus seemed that the primary growth was in the right 
vesicula seminalis and in the adjacent structures. Microscopi- 
cally Dr. Ooodhart found this to consist of a highly nucleated 
small-ceU-iufiltration of the mucous and submucous tissues. 



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8 On Purpura Hamorrhagica, accompanying 

After being hardened the kidneys showed the same kind of 
unclear growth. 

The only other part in which any new growth was found was 
the omentum, which was studded over with small flaky ecchy- 
mosed glands. The tonsils were large, but this appeared to be 
an ordinary chronic hypertrophy. The cervical glands on the 
left side were slightly swollen and fleshy. The spleen weighed 
about 10 oz. J it was soft. The medulla of the bonea was normal. 
The brain, the lungs, the heart, the liver, and the intestines 
were healthy. 

The pericardium was studded with small ecchymoses, and there 
were a few on the pleurse. The lining of the stomach was 
covered all over with minute heemorrhagic spots, and it con- 
tained a brown material — probably blood altered by the astrin- 
gent medicine which had been giveu. 

The blood throughout the body was thin, and looked like 
milk-chocolate. Yet Dr. Goodhart found no marked micro- 
scopic change in it. The white corpuscles were not in excess 
and were small. The red discs were of all sizes ; there were 
many fine granules in the serum. 

Case 3. — Purpura and hamopiyaia fifteen dayt before death j 
hematuria four days later ; hemorrhage from gums ; rapid 
swelling of the cervical glands and tonaih ; fatal cedema of 
the larynx; lymphosarcoma of cervical glanda, tonaila, 
thymus (?), and kidneys (?). 

Thomas C — , set. 30, was admitted into Stephen Ward, under 
my care, on March 23rd, 1867. He was a hawker of fish, and 
was accustomed to lift heavy weights. He was married, and 
temperate in his habits ; he had never had syphilis. He had had 
good health until February, when he began to have a cough, 
and to expectorate phlegm streaked with blood. From this he 
recovered, and returned to work until a fortnight before his 
admission. He was then suddenly seized with a dull heavy 
pain in his chest, which compelled him to give up his occupa- 
tion. The night before his attack he had had pork and greens 
for supper, as was not unusual. 

Six days later, on March 16th, a number of red and purple 
spots come out on his akiD, and on the same day he apat a 



Gl.)(.K^Ic 



the Growth of Multiple Sarcomata, 9 

qiUDtity of dark blood, without coughing. Tiro d&yB before 
admission, on the 2l8t, his urine became red or nearly black in 
colour, and it continued to be bo afteiTarda, For about a week 
he had had pain in his testicles. 

He iras a welUnoDrished man, perhaps slightly yellow in 
complexion. There were small purpuric spots on various parts 
of the body, especially round the neck and over the priecordial 
region. There were also some on the gums, and one or two on 
the inner side of the cheek on the left side. The gums were 
not sore, but were perhaps slightly swollen. The lower right 
central incisor and the anterior bicuspid teeth were somewhat 
loose ; and so, perhaps, were other teeth also. He expectorated 
a couuderable quantity of blood, which seemed to come from 
the mouth, being mixed with saliva and mucous secretion. 
There was no evidence of pulmonary hsemorrhage. The heart- 
sounds were normal. Pulse 90 j temp. 99'4°. The left tobeof 
the liver appeared to be enlarged, reaching down half way 
between the ensiform cartilage and the umbilicus. The spleen 
was much increased in size, its area of dulness extending for 
six inches vertically, and its edge being felt about half an inch 
below the ribs. The urine was of a dark red colour, containing 
red discs in abundance. 

I ordered him Succ. Limonis ^, 4tiB horis, and Tinct. Ferri 
Ferchlor. nixv, ex Aq. 3j> 6tis horis, and ice to suck. 

On the 24th it is noted that he had passed four pints of 
urine iu the last twenty-four hours ; it was very black in colour, 
containing leucocytes as well as red discs. The leucocytes 
appeared not to he in excess. The bowels had not been 
relieved for two days, and therefore he took ^n of castor oil 
on the 25th, which acted without causing any discharge of blood. 
There was slight hsemorrhage from the nares, but the urine 
became paler, and on the 28th it was free from blood. It was 
now turbid, but cleared when boiled. He still had hemorrhage 
at times from the gums, but less than when he was admitted. 
There was a considerable effusion of blood beneath the left con- 
junctiva. He spoke of himself as feeling better. His appetite 
was good. He slept well at night. The temperature remained 
at from 99-4° to 99-9°. The pulse was found to be 130 on the 
28th, but fell next day to 96. On the night of the 28th he 
had an attack of epistaxis, accompanied by headache. 



„Gooj^lf 



10 On Purpura Hamorrhaffica, accompanyinff 

On the 30th the report says :— " Last night he had profuse 
perapiratioiij and this morning at aboat 7 a-m. he noticed that 
the glands of his neck nere enlai^ed. They are very tender 
to pressure. All the other lymphatic glands of the body are 
also swollen, though not so tender. He is very prostrate, and 
has scarcely power to move his head. He ia perspiring freely. 
Pulse 120 J resp. 24 ; temp. 108°." 

On the morning of April Ist his most diatressing symptom 
was found to be extreme dyspncea. He was sitting up in bed, 
the supra-sternal and the supra-cIaTicular spaces being drawn 
in during every inspiratory effort. About noon, happening to 
be in the ward, I was startled by hearing him suddenly breathe 
very noisily. He became greatly distressed, very livid, and 
slightly convulsed. Rather suddenly the breathing ceased, and 
he fell back insensible. G-alvanism was used, but, although it 
excited movements of the arms and neck, it caused no efforts 
at breathing. Tracheotomy was then at once had recourse to, 
a flickering pulse at the wrist being still perceptible. But this 
also proved to be of no avail. 
The autopsy was made on the following day by Dr. Moxon. 
The cause of death was oedema of the entrance of the larynx, 
especially on the left side. 

The most important lesions were found in the lymphatic 
glands, the tonsils, the thymus, and the kidneys. 

The cervical glands were much enlarged, measuring one inch 
in their long diameter; they were soft, of a pinkish cream 
colour, and blotched with ecchymosed patches. The axillary 
glands were but slightly smaller than the cervical, especially on 
the right side. The condition of the mediastinal glands is not 
noted. The glands at the portal fissure and those about the 
head of the pancreas were considerably larger than natural ; 
the mesenteric, the lumbar, and the iliac glands were little, if 
at all, enlarged. 

The tonsils projected as lobulated masses, half an inch in 
thickness. On section they presented the same appearance as 
the cervical glands, and so did the thymns, which formed a 
large pear-shaped mass. 

The kidneys weighed 14 oz. ; they were very pale, and they 
were spotted all over with white patches, which Dr. Moxon 
regarded as suppurating, but which it is perhaps allowable to 

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the Gnmtk of Multiple Sareomafa. 11 

■aspect of hariDg been more or less diffused^ multiple aarcoma- 
tous growths. Between the tubules small round cells were 
infiltrated, either within the capillarieB or at least in the inter- 
stitial tissue. The pelvis (? of each kidne;} was uniformly 
reddened and swollen, and this condition extended down the 
right ureter as far as the bladder. The urethra was healthy. 

The spleen weighed SO oz. ; its substance was pale and rather 
soft. It showed a few ill-defined patches of still paler colour, 
and the Malpighian corpuscles were here and there visible in it. 

The liver weighed 128 oz. ; its tissue looked sodden and very 
pale, and there appeared to be an excess of fat in the cells at the 
periphery of the lobules. The microscope revealed the presence 
of large numbers of leucocytes, forming an interlacing network 
between the hepatic cells. 

Within the capillaries of the substance of the heart also a very 
unosual number of leucocytes were seen ; Dr. Moxon counted 
twenty-fire in a single short tract of vessel. I nay observe, 
however^ that I had examined the blood microscopically a day 
or two before death, and had failed to detect leukheemia. There 
was certainly at that time no large excess of white corpuscles. 

The pleune and the pericardium were much ecchymosed, and 
the pia mater and the peritoneum were slightly so. The coats 
of the stomach and iatestines also showed very many small 
patches of extravasated blood. 

There was early tubercular disease at the apex of each lung, 
consisting of cheesy and partly calcified masses, as well as many 
tubercles. (Probably this was the cause of the pulmonary aym. 
ptoms which had existed about six weeks before his death.) 



Case 4. — Rheumatoid pains three weeks before death ; itpot^y 
and bleeding gums; aruetnia / fever,- purpura; enlarged 
thymus ; encephaloid growth in mesentery. 
(From the Beport of Mr. H. ASBS7.} 

Alfred K — , let. 28, a coachman, waa admitted, under Dr. 
Wilks, into Stephen Ward, on April 17th, 1872. He said that 
for some weeks he bad had headache and neuralgia. His gums 
bad been very spongy, and had bled a great deal. His teeth 
had been loose and painful, and he had had severe pains running 



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12 On Purpura Hemorrhagica, accompa«ying 

up to the head. Ten days before admission he had pains in his 
joints and took to his bed. Ever since he bad had severe pains 
in the elbows, knees, and shoulders, wMcli, however, seemed to 
be diminishing in intensity. Both his father and his mother 
were alive and subject to rheumatism. He himself had never 
had gonorrhoea nor syphilis. 

He was an aniemic-looking man; his tongue was brown, hia 
breath was foul, his teeth and gums caked with blood. Pulse 
1 28 ; temp. 100'2° ; resp. 28. The heart sounds were normal. 
He complained of aching pains all over his body, especially when 
his loins were pressed. The urine, of sp. gr. 1030, contained 
no albumen. 

April I8th.— Pulse 108 ; temp. 100-2° ; resp. 26. He is in 
much the same condition, bleeding from the nose and gums ; he 
still complains of pain and tenderness all over him. Ordered 
Mist. Quinite 5ji t> d. ; Oargar. Aluminis; tannic acid to be 
applied to the gums and to the nose. 

20th. — Fains still very bad, especially in the head, so that he 
cannot sleep. Appetite bad. Bowels relaxed two or three 
times a day. 

25th. — Pulse 150 i resp, 24. Raised purple spots have ap- 
peared on the abdomen, which do not fade on pressure. There 
is no tenderness of the abdomen. 

26th.— Pulse 174; resp. 30; temp. 101-8°. Some of the 
porparic spots hare faded to a dirty colour, other fresh ones are 
appearing. There are also some small clear vesicles over the 
body. The gums and the nose still bleed. Ordered brandy 
3iv ; beef tea. 

In the latter part of the day he fell into a semi-comato&e 
condition, and died quietly the same evening. 

I made a partial autopsy on the following day. 

The brain was not examined. 

Extending from the pericardium to the thyroid body there 
was an elongated firm mass, which appeared clearly to be an 
enlarged thymus. It was whitish and yielded but little juice 
on section. 

The pericardium was ecchymosed. 

In the mesentery was a luge encephaloid mass, the size of a 
billiard ball. It contained numerous bEemorrhagic patches, 
and one large brown laminated clot exactly like that in aa 



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the Growth of Multiple Sarcomata, 13 

anearism. At one spot the ^owth reached the intestineg, and 
there was an nicer which tended to perforate the serous mem- 
brane. The mesenteric glands were widely nffected with a 
umilar growth, and also the subserous tissuea generally. This 
was especially the case in the recto-vesical poach, where there 
was a thick layer of whitish firm material. 

The liver weighed 72 oz. ; it was large and fatty, and along 
the portal canals there was some of the new growth, but in do 
considerable qaastity. 
The spleen was healthy. 

The kidneys were mottled and apparently affected with 
B right's disease. 

The bladder was healthy ; the prostate small. 



Case 6. — Purpura ; spongy gum* ; multiple growtha in and 
beneath akin, and in lymphatic glandt. 

Robert H — , aged about 35, a bank clerk, came to me in 
Febmary, 1876. He said that about a fortnight before Christ- 
mas, 1875, he had got very cold, and for three days he was 
chilled throngh. He had never been well since. He had a 
cough, and his nose was stuffed up. His mouth and his tongue 
were stuned with blood ; his gums were slightly spongy. He 
had purpnric spots on the legs, seated round the hair-follicles ; 
above the right ankle there was an effusion of blood of some size. 
About the chest there were indefinite stains, but these I noted 
to be " araociated with distinct flat thickenings." Two enlarged 
glands could be felt at the back of the neck. The temperature 
was 101°, even in the morning. 

It appeared that he was not accustomed to eat any vege< 
tables, and therefore I at first regarded the case as one of 
scorbutus, and prescribed lemons, watercresses, and other 
fresh green food, and a mixture containing the tincture of 
acetate of iron. The subcutaneous tumours I thought to 
belong to an accidental motluscum fibrosum. 

It very soon became apparent, however, that this diagnosis 
-was a mistake. He rapidly became extremely aneemic, and 
lost all his muscular strength. The lymphatic glands in.various 
parts of the body grew to large that the case was subsequently 



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14 On Purpura Htemorrhagiea, accompanying 

regarded as one of that variety of Hodgkin's disease, whic 
from a histological point of view, would be called a lympho- 
sarcoma. The subcutaneous and the cutaneous growths also 
became very numerous. He repeatedly bad haemorrhage from 
the bowelS] and once he nearly died in the water-cloaet, being 
found there in a fainting condition. I think there was trou- 
blesome epistaxis, but of this I am not sure, as I have no further 
notes of the case, having seen him only once or twice after- 
wards at his own house, in consultation with Mr. Llewellyn, 
of Wbitechapel, who attended him. He died at the end of a 
few months. There was no post-mortem examination. 



Case 6. — Fatal illnets lasting Jive weeks and a half i spongy 
gams ; mulliple tumours on scalp and body, one of which dis- 
charged Hood ; diagnosis at first scorbutus, afterwards mela- 
nosis; growths scattered in the viscera. 

Susan G — , tet. 45, was admitted into Mary Ward, under Dr. 
Pavy, on March 13th, 1861. She was extremely ill, wasted, 
and very sallow. She said that she had been ailing for about 
three weeks. A lump was found on her head, which broke and 
discharged blood ; this she attributed to a blow. There was 
also observed on the skin several lumps of a dark colour, and as 
her gums bled the case was at first regarded as one of scorbu- 
tus ; subsequently the opinion was that the disease was mela- 
nosis. She presently had brain symptoms, sank into a coma- 
tose condition, and died on March 31st. 

Dr. Wilks made the autopsy. The body was mush wasted 
and of a yellowish colour. The mass on the scalp appeared to 
have contained fibrin as well as blood. On the body were a 
number of small swellings, the largest the siise of a marble. 
These, when cut into, were found to be quite circumscribed, of 
a dark red colour, and apparently composed of fibrin; some, 
however, were very soft and contained much liquid blood. 

On the surface of the brain there were four or five red spots, 
which looked as if made up of firm fibrin mixed with blood. 
At the extreme end of the left posterior lobe was a mass, of the 
size of a walnut, with htemorthage and yellow softeuing of the 
^"^ia snbatance around it. 



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the Growth of Multiple Sarcomata, 15 

Each lung contained twenty or thirtj' firm dark red masses ; 
one, in the left lower lobe, was of the size of a closed fist. 
Similar growths existed in the liver and in the spleen ; in the 
former organ there were two, each as large as the fist ; some 
were softening in the centre. 

The heart and the kidneys were health;. 

The nterus was large ; iu its interior was a soft membranous 
layer, like a deddua. 

The cases recorded in this paper constitute a large pro- 
portion — if cot an actual majority — of all the fatal examples 
of purpura hiemorrhagica which have occurred in the hos- 
pittJ during the last twenty years. Indeed, from what I 
have seen of the occasional difficulty of recognising diffused 
sarcomatous infiltrations of the bones and periosteum in 
the dead subject, unless careful search is made for them, 1 
feel some hesitation as to whether such disease may not have 
been really present in some of the few cases which have been 
set down, even after an autopsy, as examples of Werlhof's 
morbut maculotiu. 

It is true that Case 3, and perhaps Case 5, come fairly 
within the category of Hodgkin's disease. But although it is 
well known that purpura and epistaxis and other hsemorrbages 
sometimes occur as complications of that disease, I am not aware 
of any instances hitherto recorded in which they liave been 
among the earliest and most conspicuous symptoms. There is, 
indeed, a case related by Vircbow, in the ' Deutsche Klinik ' for 
1839, and alluded to in vol. ii of the ' Krankhaften Gescb- 
wulste,' at p. 577, which (it is said), " unter dem Bilde einer 
Purpura verlaufen war." But it appears that the patient was 
admitted into the Charite Hospital moribund, and no details 
are given as to the duration or early symptoms of his illness. 

One of the most interesting features of the sarcomatous 
disease is the rheumatoid affection by which in several of these 
cases it was ushered in. This, in one instance at least, was at- 
tended with very profuse bout sweats; but it is noteworthy that 
none of the joints were found to be the seat of an effusion of fluid. 
I am sore that one cannot he too guarded in diagnosing rheumatic 
fever whenever one fails to make out definitely that the artiou* 



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IC Oft Purpura Hamorrhagiea, accompanying 

lations tbeniBelves are attacked. In this connection it Is 
perhaps worth while to allude briefly to a case vhich occnrred 
in Dr. Moxon's ward in 1876, of a man who died, after about 
three months' illneaB, of multiple Barcomatoua growths in the 
skin and the subcutaneoua tissue, as well as in the different 
viscera. In that instance there was neither purpura or hcemor- 
rhage from the mucous membranes. The chief symptom was 
wasting, for which no cause could be found, until some nodules 
of new growth became perceptible in and beneath the integu- 
ments of the chest and limbs. On referring to the clinical 
report, I find, however, that the patient stated that his illness 
originally began, eight weeks before his admission, with pains 
in the shoulders, which, after three days, were so severe as to 
compel him to take to his bed. Presently the hips, the knees, 
and the ankles, all of them became painful, one after the other. 
Whether the articulations themselves were affected seems, 
however, to be doubtful, for the report goes on to say that the 
pain extended down the limbs; it occasionally passed off for a 
time; the perspiration was not noticed to have an acid smell. 
He complained of giddiness and faintuess. 'When admitted, 
five weeks and a half before his death, his face and lips were 
described as having been anemic ; bis countenance was anxious. 
The temperature was normal, and continued to be so. 

It is worthy of notice that in at least three of the cases 
recorded in this paper the commencement of the disease was 
definitely attributed by the patient to a chill or to getting wet 
through. I know that many pathologists would maintain 
that a neoplasm cannot possibly have its origin io such a 
cause ; but for my own part I must confess that I am not sure 
of it. 

Different views may be taken with regard to the relations 
between sarcomatous growths and purpura. One is that a 
minute development of sarcomatous tissue, with vessels made 
up of embryonic cells, occurs at each spot which becomes the 
seat of an effusion of blood ; or, perhaps, that sarcomatous 
cells, or nuclei, or even leucocytes ia an abnormal conditioa, 
become lodged in the capillary vessels here and there, and 
produce softening of their walls after the manner of emboli. 
In support of such notions is the fact that in Case 1 some 
of the purpuric patches corresponded with obvious sarcoma 



.yGOOglf 



the Growth of Multiple Sarcomata. l7 

tons nodules. And in the brain it is well known that a 
sarcoma or a gHoma maf become the seat of profuse hsemor- 
rhagCj which may tear up its stmctare so that there ia 
great difBcolty in recognising it, and so that a careless 
pathol<^t may eaaily imagine the case to be a simple one of 
ordinary apoplexy. This point, indeed, must always be borne 
in mind whenever an effaaion of blood is found in a young 
anl^ect, or when it ia seated in a part of the brain, such as the 
cerebellnm or the cortex, in which there are no large arterial 
vessels. 

And in 1877 I made an antopsy which showed that even in 
the moscles, and in the lungs, sarcomatous growths may very 
closely resemble simple effusions of blood. The case was that 
of a boy, Kt. 15, who had been admitted under Mr. Cooper Forster 
for a fracture of the thigh; he had fallen while carrying two 
shatters, and they had struck on the limb and broken it. Union 
appeared to take place as usual, but sabseqaently it was foaod 
that the fractured ends of the bones were still separated. The 
thigh became very painful and greatly swollen. An incision 
vas made, and a quantity of blood escaped. Ampatation was 
performed, bnt he sank, and died in a few boars. I examined 
the parts and found them to be in a very remarkable condition. 
The original line of fracture could still be seen, the surfacea of 
the hones correaponding pretty well. Bound the upper frag- 
ment vas a thin shell of callus. All the parts were soaked in 
blood, so that at first it was very difScult to detect any further 
pathological change. Bnt on making sections of the muscles 
I found that the reddish-black blood-stained appearance did not 
fade gradually at its margins, bnt was limited definitely by 
convex edga. There were also slight iudications of a new 
growth in the medulla of the bone and about some loose frag- 
ments. In the lungs there were five or six scattered secondary 
nodulea, of the size of marbles, which repeated in a striking 
manner the dtaracters of the primary growth in the thigh. 
Th^ were of a reddish colour, and projected above the level of 
the rest of the surface. But they felt quite soft; and when 
they were cut into a quantity of blood squirted out of them 
and they collapsed, leaving cavities surrounded only by a very 
narrow margin of indefinite'looking tissue, outside which, 
again, was healtby-looking lung-substance. Under the micro- 

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18 On Purpura Htemorrhagiea, aceompanginif 

■cope the presence of a neoplasm was not much more easy of 
detennination than with the naked eye. At length, howerer, I 
ducorered in the mascles of the thigh some massea of delicate 
apindl^-cell tissue, with la^ oral nnclei, ccmtaining also cells 
of more irregolar form. In the lungs some simiUr Btractnres 
were made ont ; bat the obrioos margins of the broken-down 
secondary growths appeared to he nothing more than patches 
of a catarrhal pneumonia, the new tissue being in the centre 
of what looked like clot, filling the carities. 

But another riew is to regard the purpura, the spongy 
state of the gnms, and the epiataxia, as the joint resnlta of a 
profound cachexia or alteraticm of the blood, analogoos to thmt 
which is present in pemidoas anemia, in splenic lenk»mia, 
and, indeed, in scorbutae itself. In no fewer than five of the 
six cases recorded in this paper there was hsmorrhage firom 
the gums ; and in one of them it is noted that the teeth were 
loosened. In splenic lenknmia a morbid state of the gingival 
tissaes has been described bj Mosler; it was present in a caae 
of that disease which occurred in the hospital in 1878. 

It would be natural to speak of a " sarcomatous infection ** 
of the blood as accounting for the various symptoms under 
consideration ; but such a way of stating the matter would be 
liable to misapprehension. Case 1 is, in fact, the only (me in 
which a primary sarcomatous growth was discovered, firom 
which all the other tumours had evidently had their origin. 
It is true that in some of the cases which occurred several 
years back the presence of such a growth was perhaps not 
sought for BO carefully as we should now search for it. And it 
must be admitted that to prove the absence of a primary 
sarcoma in some one or other of the bones would require that 
an autopsy should be conducted in a manner which ia alto- 
gether impracticable. Only a few weeks ago I was examining 
the body of a man who had died under my care of wasting, 
attended with severe psins in various parts of the body ; and I 
found beneath the periosteum of a large number of the bonea, 
and in their cancellous tissues, an abundant sarcomstDua 
growth, which not only caused no tumours that could have 
been felt during life, but did not even raise the muscles ox 
show any signs of its presence until the bones themselves were 
exposed, lu that instance I could not say that any (Hie tamonr 

u,.,--, .vGooj^lc 



the Growth of Mtdliple Sareotnaia. 19 

was of older date than the others ; but it is obvtou3l7 quite cou- 
ceivable that a single iutra-osseous or subperiosteal sarcoma 
might in another case easily be altogether overlooked, the 
scattered secondary growths in the viscera being alone detected. 
Still, I must confess that I hold strongly to the belief that 
multiple sarcomata are often developed in the connective tissue 
throughout the body — ^just as a lai^ number of nodules of 
moUascum Gbrosam are found beneath the skin — altogether 
independently of any infective process. Those who adopt a 
different view seem to me often to have recourse to very 
uusatisfoctory expedients; as when, for instance, they refer 
melanotic tumours scattered in the various organs to a source 
ia some small pigmented mole, which may never, up to the 
time of the patient's death, have shown any tendency to take 
on an active growth, and may, in fact, never have attracted his 
notice. No one thinks of the growths in Hodgkin's disease as 
having always a starting-point and spreading by infection. 
Yet Aere are many cases of Hodgkin's disease in which 
deflnite tumour-masses are found bearing no relation in con- 
figuration to the tissues iu which they lie; and I think it is 
altogether impossible to limit the definition of Hodgkin's 
disease to those cases in which the growth is histologically a 
lymphoma, or, indeed, to regard it as corresponding with any 
single kind of new growth. Conversely, it is noticeable 
that in some cases of sarcoma the growths preserve the exact 
shape of the internal organs, even where the increase in 
size is enormous. In 1875 I examined a case in which there 
was an immense sarcoma of an undescended testis, weighing 
eight pounds. Along its outer side there ran a distinct rim or 
ridge, which perfectly represented the epididymis. Recently I 
was inspecting the body of a girl, set. 10, who died of a mass of 
sarcomatons glands in the neck, which were probably secondary 
to a large, firm, fleshy tumour in one side of the broad liga- 
ment of the uterus. The adjacent ovary was abont twice the 
size of the opposite one ; its substance was opaque white, and 
made up of round sarcomatous cells, yet it retained an absolutely 
normal shape. I do not think that a carcinoma or epithelioma 
ever thus adjusts itself to the configuration of the natural 
■tmctares ; and I am satisfied that (except in very rare cases, 
snch as those of double primary cancer of the mammse) those 



20 On Pttrpw^a iltemorrhagiea, Ift. 

kinds of tnmonr, when multiple, are always derived firom & 
primary Boorce. 

Ooe interesting point in the cases recorded in this commoni- 
eation is the fact that in two of them (the patients being men, 
vtat 28 and 80, respectively) the thymus was enlarged, and 
apparently affected with the growth. For in one case of 
Hodgkin's disease, which occurred in 1860 at the hospital, in a 
girl let. 10, the thymus was also found of very nunsnal size. 
It was BO likewise in the girl whom I have jost mentioned 
as hariog died of sarcoma of the hroad ligament, ovary, and 
cervical glands. But in that instance Mir. Symonds foond on 
microscopical examination that the enlarged thymus was not 
itself sarcomatonsj bat poBsesBed a normal structure. The only 
other disease in which I remember to have seen a persistent 
thymus in an adult is exophthalmic goitre. It was so in two 
out of six or more cases of this disease that have ended fatally 
at the hos]ntal within the last twelve years ; one patient was 
twenty-nine, the other was twenty-one years old. In one 
instance the organ was four inches long, and had a n 
thickness of three quarters of an inch. 



.yGOOglf 



THEUMOMETBIO SCALES. 



Bt THOMA8 STEVENSON, M.D. 



NoTwiTaBTANDiNG the almost geaenl adoption of the ther- 
mometric scale of Celrios — commonly know u the centigrade 
scale — ^by scientific men in this coantiy, and in France and 
Germany, the scale of Fahrenheit is still generally used in this 
country for meteorological purposes, and by the phyiidan. 
That of B&tamnr is but little known among ns, though it is 
the scale commonly nsed over a large portion of Eastern and 
South-eastern Europe. In eyeu the beat and most complete 
of onr English text-books the history of these scales is almost 
entirely ignored. An account of the ori^n of the three 
common thermometric scales may therefore be of interest to 
medical men, and none the less becanae the basis of Fafarenheif s 
scale is founded upon observations upon the temperature of the 
baman body. I may add that I am in great part indebted for my 
information to ' The Operative Chemist,* by S. F. Gray, a once 
weU-known book, written apparently more than half a century 
ago. The book is one now rarely met with, and this must be 
my excuse for bo lai^ely borrowing from, and even using the 
langaage of, that author. 



Fabrenseit'b Scale. 

The thermometric Ecale of Fahrenheit was devised by bim n 
little after the year 1714. In the * Acta Ernditorum ' of Uiat 

. „Gooj^lc 



22 Thermometric Scales. 

year it is stated that Fahrenheit had made two thermometen, 
to which were applied a scale, in which the difference of tem- 
perature between that of a mixture of ice and salt and that of 
the armpits or mouth of a healthy man (96'^) was divided into 
twenty-four parts ; to every four of which was appropriated a dis- 
tinct name : very great cold (supposed to be the abaolate unit 
of cold); 4 (=16°) great cold; 8 ( = 32°) cold air; 12 (=48°) 
temperate; 16 (=64°) hot; 20 (=80°) very hot; 24 (=96°) 
insupportable heat. It is probable that Fahrenheit had formed 
to himself an idea of six equal gradations (each =16° F.) of 
temperature from his point of extreme cold to that of insup- 
portable heat, butj six gradations being too few for precise 
observations, be was induced to divide them into quarters, and 
thus obtained twenty-four. 

It is not known bow soon afterwards be was led to divide 
each of these twenty-four gradations for still greater precision, 
hut in a paper of Fahrenheit's, in the ' Philosophical Transac- 
tions ' for 1724, it appears that his meteorological or spirit 
thermometers were graduated from three fixed points into 96°. 
Boerhaave states that the bulbs were blown of such a size as to 
contain so much alcohol as would fill 1933° of the scale, if it 
were produced so long. 

The three fixed points were obtained from — (1) a mixture of 
ice with sal ammoniac, or common salt, which furnished the zero 
of the scale ; (2) a mixture of ice and water, which gives 32° ; 
(3) the point obtained by holding the bulb (Fahrenheit made 
his thermometers small and his bulbs cylindrical) in the mouth 
or under the armpits of a healthy man, which gave his 96°, 
the highest limit of his original scale. This is the number 
of degrees into which the mathematician Bird divided the 
quadrant. 

Amontons having discovered that vater boils at a certaia 
degree of temperature, and other observers that the height of 
the barometer was affected by the different temperature of the 
mercury in the tube, Fahrenheit constructed some mercurial 
thermometers to ascertain the temperature at which different 
liquids boil. According to Boerhaave, these thermometers had 
their bulbs blown of such a capacity as to contain as much 
mercury as would fill 11,124° of the scale if prolonged so far; 
but the scale^ after having its fixed points detennined, as 



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T^ermomelrie Seak». 28 

already stated, was continaed to 600° only, for at that point 
the inerciii7 began to boil (mercoiy boils at 643° Fahr.)> 
With these thermometers Fahrenheit found that rain water 
bcnled at 212°. 

At present the mercnry thermometen with Fahrenheit's 
gcale are graduated £ram two fixed points only — (1) the point of 
meltbg ice, which gives the 82°; (2) boiling water when the 
barometer stands at 29'905 inches at the latitode of London ; 
the distance between these points is divided into 180°, and 
the scale con tinned np and down. 

It is a remarkable coincidence that the expansion of mercor; 
ii rerj nearly r^.W^th of its bnlk, measnred at 82° Fahr., for 
eadi increment of 1° Fahr, (one volome of mercnry at 89° 
B I'OISISS at 212°). 



RiAUlfUE's SCAU. 

Six Isaac Newton is said to have been the first who conceived 
the idea of making the degrees of the thermometric scale 
ahqnot parts of theliqnid measnred at the fireezing point; and 
lUaomai pnt the idea into practice. 

B^nmnr made use of large thermometers, whereas, as has been 
jnst stated, Fahrenheit nsed the far preferable small instm- 
mests. B&inmnr used bolbs four inches and a half in diameter, 
and their capadtf would probably be about a pint and a half. 
The tabes were a quarter of an inch in diameter. To graduate 
tbem he osed a pipette, which was filled with water to a mark 
sad its contents delivered into the thermometer. The size of 
the pipette was such that it required to be filled 1000 times 
to fiU the bulb of the thermometer and some part of the tube. 
Assuming the bulb of the thermometer to hold a pint and a 
half such a pipette would deliver about thirteen minims. The 
scale of the thermometer had a double graduation, one to the 
left, denoting the number of pipette-measures, the other to the 
right, numbered upwards and downwards, the zero being 
placed opposite to 1000 on the left-hand scale. The upward 
series denoted thousandths of dilatations, and the downward 
series tboasandths of contractions, l^hns i 



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Thermomelrie SeaUi. 



1004 


... I'ofdiUtatioii. 


1008 


... 8° 


1002 


... Sf 


1001 


... 1° 


1000 


... OPiero. 


»»9 


... 1° of coQtnotion 


998 


... 8° 


997 


... 8° 


990 


... 4° 



For meteorolc^cal pnrposes Reaumur filled hia thennoiiieter 
vith spirits of wine dilated vith water, until he found hy 
repeated trials that 1000 measures of it when ice cold expanded 
in the thermometer to 1080 when the thermometer was 
dipped into boiling water. Hence 80° of thisj the real 
B£aumar'B thermometer, was not the boiling point of water^ 
but that of the diluted spirit which he used, and, according to 
Dr. Martioe, corresponds to 180° Fahr., so that each degree of 
B^umur's scale is equal to 1-85° Fahr. 

The degrees of R^aumnr'ii scale are uaaally converted into 
degrees of Fahrenheit's scale by considering each degree of 
K&iumur as equal to 2^° of Fahrenheit. 

It is stated that this difference in the conversion of the 
scales arose thus : — M. de Luc, the French reader to Queea 
Caroline, Cktosort of George III, divided the space between the 
freezing and the boiling points of water, as marked on his 
mercurial thermometers, into 80°. Reaumur, it will be 
remembered, divided the space between 32° and 180°, i.e. 148° 
Fahr. into 80^ B&amur. Condamine is said to have advised 
de Luc to change his 80 for some other number, on the gronod 
that his scale would be confounded with B&iumur'B, De Imc, 
however, considered 80 to be a convenient number, as it haa 
several divisors, and declined to follow Condamine's advice. 
Thus, the two thermometric scales of B&amur and de Luc, 
although so different, have been confounded. De Luc's scale 
is given in his ' Becherchea sur les Modifications de I'Atmo- 
Bphire' in 1772, and is now always termed, though incorrectly, 
B&tumur's scale. 

De Luc's scale (termed nowadays R^umur's), being based 
on the graduations of a mergnrf tlienQometer, is reducible bjr 



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Themumetrie Scale: 25 

cftlcuUtion to Fahrenheit's scale. The true R^amor's scale, 
being based oa the graduation of a spirit thermometer, was not 
comparable vith Fahrenheit's, the expaiuioa of spirit being 
leas uniform than that of mercury. 



CxLSica' Scale. 

Celsina, in 1742, taking the melting point of ice and the 
boiling pmnt of water as his fixed points, divided the distance 
between them into 100°, mercury being the liquid wh(»e 
expanaion was measured. This scale was adopted in France in 
the 19th century under the name of the centigrade scale. 

Fahrenheit's is the oldest, the centigrade the most recent, 
scale of gradoation. 

The melting point of ice not being sensibly affected by varia- 
tiona in barometric pressure the zeroes of R^nmur's and the 
centigrade scales coincide with S2° Fahr. The 80° of B^aumur 
and the 100° of centigrade coincide, and they indicate the 
boiling point of water in latitude of Paris under a barometric 
pressure of 39'922 inches (760 millimetreB), The temperature 
212° Fahrenheit is not coincident with these, but indicates the 
boiling point of water in the latitude of Loudon under a 
pressure of 20*905 inches. Allowance being made for the 
differencea in latitude between Paris and London, and for the 
corresponding alteration in the effects of gravity, it is found 
that a barometric pressure of 29*922 inches in Paris is equiva- 
lent to one of 29*914 inches in London. An alteration in pressure 
from 29-905 to 29-914 inches raises the boiling point of water 
nearly one sixtieth of a degree Fahr. Strictly, the lOff" centi- 
grade corresponds to 212*015" Fahr., or 212° Fahr. corresponds 
to 99*01° centigrade. 



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D„t,M,Google 



DISTENSION OF THE FRONTAL SINUS. 



Bt CHASLSS HIOaENS. 



Ca8b 1.'— George W— , «t. 32, admitted July 10th, 1877. 
Twenty-five years ago suffered from abscess at inner canthaaof 
right eye (lachrymal sac?]. The abscess formed dnring re- 
covery £rom scarlet fever. Eighteen yean ago, he received a 
blow on the forehead from a bar of iron, but was not much 
hurt. Two years later some pieces of diaeaaed hone were 
removed from the inner angle of the orbit. Patient has been 
at sea for the last [sixteen years, as steward and cook. Has 
enjoyed fairly good health, but was never very roboat. Has 
bad typhoid fever and smallpox ; no venereal disease. 

Since the removal of bone, sixteen years ago, he has had no 
trouble abont the orbit nnttl eight months back. He then 
noticed a small lump at the inner angle of the orbit, which he 
attributed to cold taken during night watches. He noticed 
that tbe lump varied in size, being always much smaller in the 
morning, after a good night's rest, than at other times. Soon 
after the lump appeared he began to experience pain in the 
forehead, described as a kind of stretching and bearing down. 
The pain was constant, and has continued np to the present 
time. The swelling has gradually increased, and is still 
increasing, but variea in size at different times, being always 
much smaller in the morning, after rest, than in the evening, 
when he has been about all day. 

> Baport«d tn ■ Onj** Hoip. B<p.,' mt, iii, vol z^il> 1878. 

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28 Dittenaion qf the FrotUal Simu. 

On admusion, — There ia a tenae fluctnating swelliag ntaated 
at the inner angle of the orbit, above the position of the 
lachrymal sac. The skin over the swelling is nonnaL There 
is no displacement of the eyeball. An incision was made into 
the swelHng, when a large qnaotity of opaque yellow and rather 
tenacious fluid escaped ; indeed, the quantity was so large that 
there seemed to be no end to the Sow. A probe introduced 
through tl^e wound passed for two inches upwards and some- 
what backwards, and its extremity could be &eely moved aboutj 
showing that it had entered a considerable cavity. The large 
end of a Webber's sound (about the size of No. 5 orethial 
catheter] was passed with but little force through the thin 
septum which intervened between the floor of the cavi^ and 
the nasal fossa. 

July 16th. — Incision healed.* No refllling of cyst. Discharge 
escapes in considerable quantity into nose, and passes backwards 
into pharynx ; it is in no way offensive and gives no inconveni- 
ence. 

At the end of August, there was no return of the swelling ; 
the discharge had ceased running into the nose for some time. 

Case 2.— William T— , set. IS, admitted March 7th, 1879. 
Six months ago, flrst noticed swelling at the inner angle of the 
left orbit ; about the same time the eye began to water. The 
swelling has gradually increased and is still getting larger; the 
increase has been continuous, and there has been no rariatiou 
of the swelling in size at different times of the day. Never had 
any pain. No history of injury. Knows of no cause for com- 
mencement of tumour. 

On admusion. — Hard, rather irregulargrowth, projecting from 
inner margin of left orbit; it is attached to bone by a broad base, 
extending from inner extremity of upper margin of orbit almost 
to level of inner canthus ; it passes backwards into ^e orbit. 
The eyeball is pushed outwards ; its movements are perfect ; 
sight normal, there is no diplopia; nostril quite free; no teeth 
missing. Tumour looked upon as an exostosis from the inner 
wall of the orbit. 

March lOth. — Patient placed under the influence of an anses- 
thetic. Incision made over tamour ; cutting forceps applied to 
growth crushed through it at once, there being only a tbia 

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IMgtention of the Pronial Saua. 20 

bWI of bone ; a quantity of grey, opaque, teoaciooB macni 
escaped. The finger, passed through opening made by forceps, 
entered a lai^ cavity, which extended for some distance 
upwards and somewhat backwards. A drainage tube was passed 
through the floor of the cavity into the nose, and its upper end 
fixed by strapping to the forehead. Carity to be syringed 
out daily with solution of carbolic acid, 1 to 40. 

June Srd. — Drainage tube removed. 

16tli. — Fistnlons opening at inner angle of orbit; discbarge 
escapes into nose. No air escapes through fistula on forced 
expiration with the nostrils and mouth closed. Still consider- 
able thickening of bone. 

Jnly 21st. — Fistula smaller, but otherwise the same. 

October 6th,1879. — Swelling much contracted, small fistulous 
opening admitting a probe, which passes backwards nearly two 
inches ; cari^ quite small ; epiphora ; still some discharge into 
nose. 

January I9th, 1880. — Thickening of nasal bone, nasal process 
of superior maxilla, and internal angle of frontal bones; situa- 
tion of wound marked by small puckered cicatrix, in centre of 
which is an opening admitting No. 1 lachrymal probe j the 
probe can be passed for I) inches backwards, but in no other 
direction. There is some epiphora. 

Case 8^— Elisabeth S— , at. 19, admitted March 10th, 1879. 
For the last e^ht months has noticed a lump at the inner 
angle of the left orbit, and watering of the eye. The lump 
gradually increased in size, but has always been larger when 
walking about than when lying down. About four months 
ago an abscess formed and was opened, the wonnd never closed, 
and a constant thick yellowish discharge issued from it. Patient 
knows of no cause for the swelling ; does not remember 
having received any injury in its neighbourhood. 

On adnutaion. — There is a large dusky swelling at the inner 
angle of the left orbit ; a constant discharge of thick yellowish 
■emi-porulent looking fluid takes place £rom an opening in its 
centre ; a probe introduced through the openii^ passes down- 
wards towards the lachrymal sac; there is expansion and 
i^parentiy thickening of the bones about the inner angle of the 
orUt ; no disjdacement of the eyeball. The swelling, though 

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so ZHtteruion oj the Frontal Smus. 

not in the position of the lachiymal sac was thought to com- 
mtinicate with it. 

The fistnla vu laid open, the upper and lower canalicnli slitj 
a probe passed down the nasal dact ; there appeared to be no 
stricture. Three weeks later the fistula was closed, and the 
swelling had greatly diminished. 

May 19tfa, 1879. — Fistula has reopened; swelling as lai^e as 
ever. Patient readmitted. A free incision made into swelling 
openedalargecavity,eTidently the distended frontal sinus. Some 
of the bone was chipped away, and a quantity of thick, tenacious, 
mnco-purulent fluid allowed to escape. A probe introduced 
into the cavity passed scross the middle line to the other side 
of the forehead. The cavity was thoroughly cleared out, a 
strong iron probe pushed through its floor into the nose, a 
drainage tube passed through opening thus made, and left with 
one end protruding from the left nostril, the other from the 
incision. Some small polypi were found in the left nostril, 
which might possibly have caused obstruction, leading to dis- 
tension of the sinus ; they had up till now escaped observation. 
Cavity to be syringed daily with carbolic lotiou. 

September 8th, 1879. — Drainage tube removed. A quantity 
of thick mucus is still escaping; swelling has diminished; air 
passes freely through the opening on expiration with the 
nostrils closed, 

October 6th, 1879. — The swelling has greatly diminished. 
A cicatrix and small fistula mark the spot where the opening 
was made ; probe passes about an inch through fistula ; its end 
can only be moved about to a limited extent, showing that the 
cavity is much contracted. 

January ISth, 1880.>— The fistula has entirely closed ; nothing 
now remains but a little drawing back of the inner cantbaa. 
Some thickening of the bones and alight epiphora. 

The disease under consideration cannot be so very uncommon, 
for I have myself treated three cases, and have seen four others 
the sabjects of which dediued operative interference ; in one 
of the latter the tumour was very large indeed, and had existed 
many years. 

Yet in many of the text<books, no mention is made of " dis- 
tension of the frontal sinos" oi anything equivalent to it. 
Thus, in the Burgical works of Holmes, Bryant, and SncHaen, 

■ , GoeK^Ic 



IXatention of the F^rotUti 8imu. 81 

■nd the ophthalmic vritingi of Carter and Btellvag — so far aa 
their indices are concerned— the sabject is not touched upon. 

I Biupect that this omisdon may be partly dne to the fact 
that BDch caaes come indiscriminately nnder the care of both 
the general stageon and the specialist ; and in their writings 
the former have left the description to the latter, and vice vertd. 

In ' Holmea's System of Surgery/ the disease (if it be the same) 
is diimissed aa followB : — "X would, however, just mention a very 
nirgttlar tamotir spoken of by MM. B£rard and Denoarilli^rs, 
formed apparently by distension of the frontal sinus, producing 
intense pain, displacement of the eye, and a large accumulation 
of gas in the superficial parts of the fooe, commauicating with 
the neck." 

In the following works the disease is treated of nnder the 
Tsrions names of Distennon of the Frontal Sinus, Encysted 
Tumour, Chronic Absceas or Mucocele, Enlai^ement of Frontal 
Sinus, and Hydatid. 

Mackenxie^ ' On Diseases of the Eye,' under " Encysted 
Tomoora or Hydatids of the Frontal Sinna," says : — " Pro- 
fessor Langenbeck haa published two cases of pressure on the 
orbit &om disease in the firontal tinns. He speaks of them as 
cases of hydatid, a term much misplaced by German patho- 
logiats. Binger would probably have regarded them aa cystic 
or encysted tumours. Perhaps the one was nothing more than 
a collection of mucus and the other of thick matter. The situa- 
tions of the protrusion of the outer table of the bone are 
amongat the most remarkable circnmstances of these cases." 

The cases are briefly as follows : 

Cabe 1. — A female, st. 17, when eight years of age, in ISOS^ 
foil and struck right temple against sharp comer of table. 
Soon after a hard swelling appeared in region of right frontal 
sinos. Swelling painless ; extended gradually till it iavolved 
whole of right side of frontal bone. The right eye became dis- 
pUoed downwards and ontwards, vision gradually decreased. 

In 1818' the swelling was opened. Through the opening 
there was discharge of clear, ropy, lymphatic fluid, escaping 

' There appaui to be toma miitaka aboat the dale or age of the patient at the 
tdae of opentioQ. Bhe U «aid to hare been eight jears of age in 1B02, bnt 
pnnuiiablj the report waa taken about the lame time that the operation was 
pnfonnsdi if ntih wen the out iheirotild bare been twen^-lour, not wruitMB. 

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8S DutentiM of the Frontal Sinui. 

from a wbite shining cyst, which filled the whole frontal 8iaas> 
and had been penetrated by the perforator. 

The cyst or hydatid, as the narrator of the case styles it, 
was laid hold of with forceps and partially extracted. Measure- 
ment of the cavity showed it to be three inches across, and 
three and a half inches from before backwards. The sinus was 
filled with lint; injections of willow bark and myrrh, and 
subsequently of corrosive sublimate, were used. 

When the patient left tbe hospital the Bwelling had subsided 
but little. The following year she returned, with the swelling 
in much the same condition, the discharge of matter being 
abundant. Two setons were passed through tbe sinus, by 
which means the discharge and swelling diminished. 

Cabb 2. — Male, set. 20. Eleven years before admission 
received a stroke with a racquet on the left side of nose and left 
eye, the consequence of which was a great degree of swelling, 
which after a time completely subsided. 

Two years later he began to have pain, and noticed aome 
protuberance at the inner angle of the eye. 

When the patient came to the hospital, vision was nnaffected; 
the eyeball was pressed outwards and downwards by a consider- 
able swelling at the inner angle of the orbit. The swelling had 
exactly the appearance and situation of a greatly distended 
lachrymal sac, but was considerably bigger, could not be 
emptied, nor could any fluid be made to escape from the tear 
puncta on pressure. 

Tumour was cut down on; a white glistening sac came into 
view. On opening the sac a greyish-white, tenacious fluid 
escaped; depth of cavity was three inches; flnger introduced 
into it reached as far as the floor of nostril. Termination of 
the case ia not given. 

Walton, ' Practical Treatise on Diseases of the Eye,' says, 
nnder "Disease of Frontal Sinus :" — "Encysted tumours may 
be a real dropsy of the cavity or merely a collection of pus or 
hydatids." 

He gives a case of distension of the right frontal sinus by 
mucus, in a girl set. 20; tbe bony wall of the sinus had 
become absorbed. The swelling was punctured and a small 
dnduage tube introduced ; the cavity was frequently syringed 
out J a fistulous opening remained for a long time. 

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THitention of the Frontal ^fuu. 83 

GaDt, ' Science and Fnctice of Surgery.' " Chronic abacen 
or mucocele may result when the commnnicatiDn between the 
ethmoidal cells is closed up and mnco-pomlent matter aconmn- 
latea in the sinns." " The swelling may be mistaken for • solid 
tamoor or growth witUa the ainos, but at a later stage the wall 
of the sinns becomes thinned and points, and the fluid chaneter 
of ita contents can be felt with the finger." 

He recommends that the communication with the ethmcndal 
cells and nose should be re-eatablished, care being taken to 
maintain the communication for some days whilst dilute 
astringent injections arc used ; that the cavity should be dosed 
aa soon aa possible, lest a fistulous opening remain, forming 
with the nasal passage an aerial fistula which would be difficult 
to close. " A cyst, hydatid or &tty, is sometimes produced in 
the frontal sinus, giving rise to similar symptoms, and reqoii- 
ing the same treatment." 

Soelberg Wells, ' Treatise on Diaeases of the Eye.' " Diseaaea 
of the frontal sinus may prodnce considerable dilatation of this 
cavity, which then encroaches on the orbit, giving rise to con- 
traction and malformation of the latter, and consequent pro- 
trusion of the eyeball," Diseases mentioned are — acute and 
chronic inflammation of the lining membrane, giving rise to 
purolent or maco-puralent discharge. Polypi, cystic tumours, 
entOEoa, and exostoses are also mentioaed. A blow is given as 
the cause. The treatment recommended ; a free incision, 
thorough evacuation of the contents, a seton passed through 
between sinus and nasal cavity, and left in for several weeks. 

Hulke, ' Royal London Ophthalmic Hospital Kc^rts,' vol. 
iii, pp. 152, 153, gives two cases of distension of the frontal 
sinus. One is apparently the same as that reported by Walton. 
No canse is given. In the other there was a history of injnry 
twelve years before. It was treated by incision ; the discharge 
became purulent ; pnmlent character and qnantity of discharge 
diminished, and at the end of the following month (abont air 
weeka from the time of operation) only a few dropa of mucua 
escaped morning and evening from a small fiatola, which the 
wound had then become. 

Two yeara later the eye was still slightly in advance of its 
fellow, the orifice of the sinus had become almost capillary, and 
only occasionally discharged a few drops of clear mncns ; some 

VOL. XXV. 8 

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34 Diiiention of the fVontal Sintu. 

enlargement of upper part of nasal process of superior mazfUft 
and internal angular process of frontal bone remained. 

Lawson, ' Diseases and Injuries of the Eje/ describes " Dis- 
tension of the frontal sinns " very fully. He gives injury at 
soma time — perhaps very remote — as the most common canse. 
Two cases are reported : one in a maoj eet. 58, in whom the 
disease nas traceable to a kick from a horse fifty-foor yean 
before; the other in a woman, set. SI, in whom the swelling 
had bMn first noticed six years before consulting Mr. Lawson, 
and was attributed to an attack of erysipelas fifteen years beftre. 
The treatment in both casea was by iatroduction of a drainage 
tabe, and syringing with astringent and disinfectant solutions. 
Mr. Lawson says the drainage tube should be worn for five or 
six months, or nntil all discharge from the nose has ceased. 

Bader, ' The Human Eye, its Natural and Morbid Changes,' 
says : " Most commonly the sinuses are enlarged by accumu- 
lation of thick transparent or partly opaque mncua, or by muco- 
pus, rarely by pus ; this may be fstid and mixed with blood." 
" In rare instances solid bony tumours, exostoses, and polypi 
attached to the walls of the sinns, or enoroaobing from neigh- 
bonring centres, have been found." lujury was found to be 
the cause in eight oat of nine cases. 

The treatment recommended is incision and introduction of a 
seton through the sinus into ^the &c»e. The seton may be 
removed four weeks after introduction, but in some cases faaa 
been left in for several months. In one case the seton, a wire one, 
setup BO much irritation that ithsd to be withdrawn. The patJCOt 
daily passed the handle of a cstaract knife through the nose into 
the opening, and " finally sncceeded in restoring the normal 
dimensions of the sinus, and its communication with the nose." 
Bader alludes to a case in which some insect had become 
lodged in one of the sinuses, and caused irritation of the mucous 
membrane. Benefit was derived from smoking cigara impreg- 
nated with arsenic. 

Distension of the frontal sinus appears to be caused, in many 
instances, by a blow abont the inner angle of the orbit, causing 
fracture of bone and subsequent closure of the communication 
between the sinus and middle meatus of the nose. The blow 
may have been reoeived at a period very remote from the fint 
appearuioe of the tumour. In the fint of my caaea the iqjwy 

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Diatenaion of the Fironlal Smus. 35 

was more than seventeen years beforCj and in one of Mr. 
Lanaon's, when the patient was first seen by him, fifty-four 
years had elapsed since the injury; the report, however^ doet 
not say when the tumour was first noticed ; it was very large 
and had probably existed some years. 

The great length of time between the cause and its risible 
effect may be accounted for by supposing that the distension 
gives rise to no very marked symptoms until the orhital wall 
of the sinus begins to bulge, or, indeed, until the bone having 
become absorbed the contents of the sinus point beneath the 
integuments. The secretion of the sinus is probably only 
sufBctent to keep the surface of its cavity moist, and^ — providing 
no inflammatory action was set up— would take years before its 
quantity was sufficient to cause distension. Moreover, before 
bulging the external walls the secretion might make room for 
itself by destroying the partitions between the various cells, 
not only frontal, but ethmoidal, or by passing across the middle 
line, and in part discharging itself into the opposite nasal 
cavities. Thus, in my third case there was evidently a com- 
munication between the two sinnses, for a probe could be passed 
from the incision quite over to the other side of the forehead. 
In this case, as in Case 2, there was no history of injury, nor 
could any cause be assigned by the patient for the appearance 
of the tumour. It is possible that the polypi found in the 
nose may have blocked the opening of the sinus ; they were, 
however, so small that they bad given rise to none of the 
ordinary symptoms of nasal polypus. If they were the cause of 
the obstruction they must have grown quite close to, or in, the 
opening of the infundibulum itself. 

Distension of the frontal siuuB has probably no early sym- 
ptoms. There is at no time severe pain, nor indeed any, until 
the disease has far advanced. In my first case the patient had 
no pun until after the lump appeared at the inner angle of the 
orbit, though in all probability the sinus had been gradually 
filling for sixteen or seventeen years. The pain was described 
as stretching and bearing down, and was constant. In the 
other two cases no pain was complained of. 

The first symptoms noticed by the patient are swelling about 
the inner angle of the orbit and perhaps epiphora, the latter 
being dependent on the former. 

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86 Distention of the Fi-ontal ^nut. 

A tumour having formed, its nature is not bo very endeat. 
In the first of my cases I formed no opinion beyond that there 
was a collection of fluid pointing above the inner canthns .1 
did not think it was a distended sac ; an incision, followed by 
the introduction of a probe, showed plainly what it was. 

In the second case I disposed an exostosis of the oibit, and 
in the third an abscess connected with the lachrymal sac. 

The diagnosis between bony tumour and distension (tf the 
firontal sinus — before perforation of the bone has taken place — 
is not easy. We h&ve, as in Case 2, an inegalar tumour pro- 
jecting from the inner margin of the orbit, hard, and apparently 
connected with the bone. The tumour feels like bone, grows 
slowly and painlessly, as bony tumours do, so that both in their 
physical characters and history the two agree. Later on, how- 
ever, in distension of the frontal sinus, the bone, already thin 
enough, becomes thinner, and on pressure upon the tumour a 
crackling sensation is communicated to the lingers. No sach 
thinning takes place in the exostoses found about the orbit ; 
they are very hard and dense, and feel so. 

A correct diagnosis is easily arrived at by cutting into the 
tumour. 

When the bone has become absorbed and the contents of the 
sinus point, a rounded, fluctuating swelling is formed, which 
may be mistaken for a distended lachrymal sac. There are, 
however, certain marked differences between the two. Thus, the 
position of the swelling in distension of the frontal sinus is 
different j it is high up at the inner angle of the orbit, above 
the tendo oculi, instead of beneath it ; it cannot, like the 
distended sac, be emptied by presaore, nor can any of its contents 
be squeesed out through the canaliculi. At this late stage the 
tumour caused by distension of the frontal sinus has one marked 
pecnliarity, it variei in lize at diferent timet of the day. 
Patients tell us that swelling is much leas when they get up 
in the morning than at other times. This is probably due to 
the fluid becoming — when the patient lies down for some time — 
evenly diffused throughout the sinus, whilst it gravitates to the 
lowest part after the erect position has been maintained for a 
few hours. In this stage, as in the earlier ones, an incision 
into the tumour will clear up any doubt. 
Displacement of the eyeball, diplopia, and impairment of 

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Dutetuion of the Frontal Sima. 87 

▼isioo may occnr or Dot, according to the site the tnmoar hu 
reached. 

Diatenaion of the frontal sinoa ii, I think, beat treated by 
drainage. My firat caae did well with aimply an indaion 
through the int^amenta, clearing oot of the sinns, and a 
coanter>opening into the noae. The patient^ however, dis 
^ipeared before anfficieut time had elapsed to allow of refilling 
of the cavity. 

The other two caaea have been aeea occaaionally ap to the 
preaent month (January, 1880). In one the operation waa 
performed ten montha, in the other eight naonthsj ago ; 
the drunage tube was left in rather leas than three months in 
Case 3, rather lesa than four montha in Case 8. The lesult in 
both is in every way satisfactory, but more especially in Case 2. 
In Caae 8, a small fiatulons opening still remains, and there is 
aome thickening of the bones about the inner angle of the 
oririt. 



Since my paper waa sent in the following caae has been 
operated on: 

Z. F— , »t. 86, first came to me in April, 1876. Had 
alwaya enjoyed good health ; never had any venereal disease. 
For eight years he had been at aea ; for five yeara anbaeqnently 
be waa a "seaman'a labonrer;" during tbe next five yeara he 
was employed as a clerk, working long honra in a dark office. 
When abont fourteen years of age patient had a kick above one 
(^ hia eyea, but he doea not remember which. Seven yeara 
ago had a blow above one orbit (ia almoat sure it was the left) 
from an iron rod connected with a ateam hammer. Alwaya 
enjoyed good sight until he became a derk (five yeara ago). 
Soon after commencing his duties he firat began to notice a 
doll pain at the inner angle of the left orbit, extending np the 
forehead in the course of the aupra-orbital nerve, and along the 
inner aide of the noae ; this pain was always worse after he had 
been engaged for some hours in writing. One day, while in 
great pain, he covered up bia right eye, and then found that 
the sight was defective in the left. He had some drooping of 
the left upper eyelid at this time, hut is not sore when it first 
began. Hia wife had noticed a difference in hia eyes for a 
year or more previooaly. 

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38 DUtetuioH of Ike Frontal Sinia. 

Whea fint teen lie oomplained of pain in the left eyeb&li 
and orbit, which had been almost constant during the laat 
twelve months ; the right eye had become rather painful in the 
last fortnight. He had ptosis ; the note does not say on which 
side, it was probably the left. 

The right eye could read Snellen 40 at twenty feet, and 
Snellen 80 at the same distance, by the aid of a convex glass of 
twenty-four inches focus. The left eye could read Snellen 50 
at twenty feet without aid, with a convex lens of forty inches 
focus Snellen 30 at twenty feet. The ophthalmoscope showed 
hypermetropia in both eyes. He was ordered to use convex 
24 for all near work. 

He did not get much benefit from the spectacles ; the pain 
in the left eye went on increasing; be went on with his work 
though advised not to do so ; he took iodide of potassium for 
some time. 

On June 28th, 1876, it was noted that there was a good 
deal of pain about the pulley of the left superior oblique 
muaole. 

Oq July I9th the refraction was tested more carefully, and 
astigmatism found in the left eye. Suitable glasses were 
ordered. He managed to see very well with these, but the 
pain in the left eye and orbit continued. 

No note was made of any swelling about the orbit or dis- 
placement of the eyeball. Beyond the ptosis noticed at his 
first visit nothing but the hypermetropia and astigmatism was 
made out, and to these the pain and discomfort were attri* 
bated. 

December 29th, 1879. — During last five mouths left eye has 
become prominent. There is now protrusion of the eyeball, 
which is also pressed downwards and outwards by a paiii^)), 
semi-elaatic swelling, projecting from the inner and upper part 
of the orbit. A month ago the swelling was inflamed, very 
painful, and much larger than at present. Vision ia somewhat 
impaired (f^ instead of f^ with apherico-cylindrioal lens). 
There is no diplopia. The ophthalmoscope shows that the 
inner edge of the optic disc is veiled, and its inner half very 
red. 

Periosteal node diagnosed ; ordered Pot. lodidi gr. xx, Tr. 
Cinch. Co. n\.xx, Aqua 5j> ter die. 



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XHtiention t>f the Frovial 8inu». 39 

febraary 6tb, 1880. — -SwelliBg more solid, decreased in sizej 
QO pain except on exposure to cold or attempting to read. 
Obicnre flactaation in parte. Omit iodide. The swelling is 
larger at some times than at others, and when patient lies down 
partially disappears. It was now diagnosed to be the distended 
frontal sinus. 

12th. — Patient placed under influence of an anaesthetic. A 
hard, immovable turannr could be felt projecting into the 
orbit from its inner angle ; no fluctnatioD could be detected. 
The swelling was cut down npon, and a mass of hard bone 
exposed, in the centre of which was a small opening, from 
which some thick pus escaped. Some of the bone having been 
broken away the finger entered a lai^e cavity, and conld be 
passed downwards, backwards, and inwards for about two 
inches and a half in each direction. A large qnantity of thick, 
greenish, fetid discharge escaped. 

A perforation was made from the cavity into the nose, and a 
drainage tube introduced; some sharp ridges of bone were 
removed with bone forceps ; after this the eyeball returned to 
nearly its natural position. Cavity to be syringed oat daily 
with carbolic lotion (1 to 40). 

16th. — No bad symptoms; some swelling of the eyelids, 
subsiding. Eyeball pressed slightly outwards and downwards. 

23rd. — Noticed impairment of sensation of region of dis- 
tribution of supra-trochlear nerve (no doubt divided at opera- 
tion). 

March 26th. — No return of sensation; smaU abscess at 
upper opening for drainage tube. Optic disc still red at inner 
side, and margin ill defined. 

May 6th. — Has had some inflammation of the upper eyelid 
aod around entrance of tube. There is some thickening of the 
bone close to the inner angle of the orbit ; still some discharge 
from the lower end of tube. Eyeball in nearly normal position ; 
vision as good as ever. Optic disc rather red, but its outline 
quite well defined ; patient has been at his work as a clerk for some 
weeks, and by the aid of glasses can write or read for any time 
without pain or inconvenience. New drainage tube introduced. 

In this case there is a distinct history of injury. Some of 
the symptoms complained of were no doubt due to the hyper- 
metropis and astigmatism, and, as commonly happens, were 

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40 DUleiuion of the Frontal iStntif. 

first noticed when the patient began to nse the eyes con- 
tinaoosly upon near vork (in hia case vriting). 

The BjmptoiQB caoBed bj the anomaly of refraction and 
those dne to stretching of the vail of the frontal Binns were 
mixed np together ; the pain was not entirely due to the formerj 
as it waa not relieved by suitable glasBes, although the sight 
was greatly improved. This circumstance, coupled with the 
existence of ptosis, raised a suspicion that there might be some 
periostitis about the orbit, or some disease within the skull, 
but the true nature of the case was nerer suspected during the 
whole time that the patient was under oI»erv&tion in 1876. 

In 1879 the displacement of the eyeball was evident enough ; 
its cause was also plaiu, but not bo Uie nature of the tnmonr. 

Unlike the other cases, pain was a very prominent symptom 
here, and there was one rather sharp attack of inflammation. 

Soon after this the patient noticed that the tumour varied in 
size at different times ; this is one of the chief diagnostic signs 
of "distension of the frontal sinus," and cannot occur until the 
bone being absorbed the contents of the sinus point beneath 
the integoment. 



.yGOOglf 



NOTE 

OJ Till 

TaiANGUIjAB LIGAMENT OP THE 
URETHRA. 



Bt B. B. CABEINGTON, M.D. 



Thb oonnections of the trimgalar ligament of the nntlira are, 
in mj experience, involved in a couiderable amount of con> 
fnaion. That snch is the caae ia constantly being forced npon 
one's notice in the dissecting room, and conaeqnentlf I have 
directed some little attention to this point of anatomy. I have 
therefore thought it might be of some little nae to wiite this note 
with the view of endeavoariog, so far as I am ab]^ to make the 
oonnections of this stmctnre clearer. The difficnlty arises, I 
believe, from tiro canses : firstly , that identical parts of the 
pelvic fascia have received a different nomenclature; and 
teeondb/, Uiat incorrect, or at all events inexplicit accounts, are 
given in most of the text-books in ordinary ase. 

To obviate the first difficulty, I shall take that account of the 
pelvic fascia which ia now commonly received, and indeed 
followed by the authors usually read; bat the connectious of 
the various parts of which with the structure under considera^ 
tion are either not stated exactly, or are else erroneously 
fnven. I mean that description which says that the pelvic 
fascia divides, at some point in a line extending from the 
symphysis of the pubes to the spine of the ischium, into two 
parts, one of which extends in to the various pelvic viscera, and 

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42 Triangular Ligament of the Urethra. 

the other of which is coDtiaued dowD on the inner surfaee of 
the obturator interaus muscle to the outlet of the pelvis. Tlie 
line of bifurcation is called the white line, the part of the fascia 
above this line is uamed pelvic, the portion below obturator, 
and the piece extending in to the viacera recto-vesieal ; further, 
there is a thin fascia derived from the obturator, which lines 
the under surface of the levator ani muscle, to which the name 
anal ia applied. 

But whilst laying down these hard-and-fast lines, I will qaote 
here a passage from ' Quain's Anatomy ' (vol, i, p, 337), 
because, whilst I have been' repeatedly convinced of its accuracy, 
I do not think any other of the authors, ordinarily read, mention 
the facts stated therein. It is as follows : 

"The obturator fascia is aometimea included in the descrip- 
tion of the pelvic fascia, while the recto-vesical is considered as 
an offset from it. It will be found however on dissection, that 
the rectO'vesical fascia is always most directly continuous with 
the pelvic fascia, and that the obturator fascia is only loosely 
connected with it. Indeed, the fibres of the levator ani muscle 
in moat cases pass upwards to some extent beyond the white 
line, and thus separate the obturator from the pelvio fascia." 

I will now take the various descriptions given of the ana- 
tomy (^ the triangular ligament.^ It will be found that there 
is no difficulty about the anterior or superficial lamella, for this 
is described by all as a special layer of fascia clotvig the upper 
part of the pubic arch. It is in the connections of the deep 
layer that the discordant accounts, real or apparent, are given. 

Thns, in "Gray's Anatomy" (p. 761) it is stated "the 
posterior layer is derived from the pelvic foMcia," a,jid agiin (pp. 
7B6-56) the pelvic fascia "is continuous below the pubes with 
the fascia of the opposite side, so as to close the front part of 
the outlet of the pelvis, blending with the posterior layer of 
the triangular ligament:" and further, the obturator ^fascia 
" is a direct continuation of the pelvic fascia below the white 
tine, and ig attached to the pubic arch" The inference from 
this account is, I take it, that the posterior layer is formed by 
the pelvic fascia closing the pelvis in front and beneath the 
symphysis, and that the obturator division takes no part in the 

' Tho italic* ue mj own va all the incceeding quotation*. 

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Triattifular Ligament of the Urethra. 43 

formation of the triaogular ligament, bnt stops short at the 
pubic arch. 

In ' Quain's Aaatomy' (vol, i, p. 326) we find "this layer 
(i.e. deep layer of triangular ligament) is superficial to 
the anterior fibres of the levator ani, which lie between it 
and the pelvic fatcia,^ and is connected with a thin web af 
areolar titsue, which extendi backwardt on the »ur/ace of 
Ike levator ant muscle and it distinguithed at the anal fatcia." 
The obturator divisioQ is described as being attached to the 
rami of the pubes and iachiutn. 

There is nothing said as to the connection of the triangular 
ligament with the pelvic fascia, or with any part of it, and I 
think that we must either infer that both layers of the ligament 
avo to be looked upon as tpecial fatcia, or that else the deep 
layer is derived from the anal/atcia, 

III ' Holden's Manual ' (p. 369) the matter is very briefly dis* 
posed of, and it is simply stated that " the posterior layer (of 
the triangular ligament) is apart of the pelvic fatcia." 

In Heath's account of the triangular ligament, no mention 
is made of its connection with any part of the pelvic fascia, but 
in describing the recl0-v«Mca/ ^ayer (p. 361), the following is 
stated : " It is seen to dip down to the prostate, and is thus 
continued from one side to the othw of the pelvis, of which it 
closes the outlet." 

In ' Ellis's Anatomy ' (eighth edition, p. 546), no distinction 
is made between pelvic and obturator fascise, but the whole 
membrane lining the inner turfaee of the obturator mutcle it 
called pelvic, and the following statement is made ; — " Inferiorly 
the fascia ia attached to the hip-bone along the side of the 
pubic arch," He is here speaking of the part below the white 
line, i.e. the obturator division of other writers. On p. 549, it 
is stated that the recto- vesical fascia between the pubo-prostatic 
ligaments of opposite sides " dipt down to reach the triangular 
ligament of the perinteum, and cloiet the pelvis between the 
tevatoret ani," On p. 429 we find, " the posterior layer (of the 
triangular ligament) is derived from the recto-vetical fatcia. 
Here, then, we have another account of the origin of this layer. 

■ The voti pelvic miut here be read In connection with the pnuage qnotcil 
•bore (vol. i, p. 327). Bteto-vttical ii probubly meKuf, >b being s direct contiDB*< 
tion of tte fthie/aifia. 



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41 TVianffular lAgameta of the Urethra. 

I m&y here note that in the sixth edition of this writer's 
work (p. 587) the account given of the pelvic &scia differs 
Bubstantiallf from the later one just quoted ; in that it (the 
pelvic fascia) is stated to be " continued from the one h^-bone 
to the other, $o as to close the cavity of the pelma in front for a 
thortdiatance;" andthaton p.468, it is said, that "the posterior 
layer {i.e. of the triangular ligament) u derived from the pehne 
fascia. We muBt however of course t&ke the later description, 
which gives the origin from the recto-vesical fascia. 

I think I have quoted enough to justify the statement that 
the connections of the posterior layer of the triangolar ligament 
may well be a stumbling-block, for we have the foUowing 
different accounts given : — ■ 

1. From the pelvio fascia (Gray and Holden). 

2. A special structure, or £rom the anal fascia (Quain). 

3. From the recto-veaical foaoia (Ellis). 

It seems to me that the following considerations may make 
the matter clearer: 

1. The pubio oioh is of coune below the level of the 
symphysis. 

3. The white line extends flrom the lower part of the sym- 
physis pubis. 

Therefore the triangular ligament mtut be below the level of 
the pelvic fatcia, which only extends as far down as the white 
line. 

I believe the true acconnt, and it is one which I have verified 
by dissection, to be as follows : — 

The superficial layer is a special fascia. All accounts here 
agree. The deep layer is formed by the obturator fascia, which 
anteriorly is fonnd to stretch across the pubic arch and close 
it ; or perhaps a little more exactly, the obturator fascia may 
be described as running down to be fixed to the margin of the 
pubic arch, and a little above its attachment, to give off a process 
which passes across the upper part of the arch, and which, 
joining with a like process from the fascia of the opposite side, 
forma the deep layer of the triangular ligament. An additional 
proof that this is the true formation of this layer is found in the 
fact that the triangular ligament extends as far back on each 
side as the tuber ischii, where it is, of course, far below the 
level either of the pelvic, recto-vesical, or ooal fascite. 

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Drianguiar Ligament of the Urethra, 
Fis.1. 



DtiBjux aw TBI PoBrmoK Bvxixom oi mm SntrBttu Pvbii, nowaa 
TBI Dimiosa ov thx Pkltio Fabcu, Ajn> tks ContscnoH oi isb 

PomUOB L&TKB OT THB TUASaULlB LiGUfBBT. 

B. Bladder dmro backward*. 
P. ProaUte. 

Cp. Pabo-proatatic li^mmta. 
h. Anterior fibn» (n the leratorei ani maacles, ariiiag rrom the 
lower part of the lymphjgia pnbia. 
T, T. The poat«nOT lajer of the triangular ligament, contiunotu later- 
aUj with the obtnntoT fudai. 

The white line* coireapond to tbe cat edge* of the recto-veiical fucis, 
and tbe pabo-proitatic ligunenta to the anterior edges of the ■■me. 
Between tfaete two there ia a triangolar interral v iu the median line, in 
which tbe recto-veiical fatds dip down to join the poaterior lajer of 
the triansnlar ligament and the capmle of the proatate. 

The piiiM>-pTOrtatic ligaments are on a higher level than the leratorc* 
aoi mnacle*. 

If, therefore, in Gray's accoim^ for pelvie we write obturator, 
it vodM be correct. The triangular ligament ia coDtiniioni 
behind with the anal fascia, but I do not think that the second 
alternative of Quain's description is right, viz. that the pos- 
terior layer is derived &om tbe anal fascia, for this would be 
tracing a comparatively thick membrane firom a very thin one; 
and as to the first, that it is a special structure not connected 
with any division of the pelvic fascia, I would say that I have 
often traced its continuity with the obturator, as follows : — 

If tbe obturator fascia be separated from the outer wall of 
the ischio-rectal fossa, and the dissection is carried forwards 



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44i Triangular Ligament of the Urethra. 

along the pubic arch, keepiug close to the bone, the triangular 
ligament will also be detached; the knife will not pass between 
these two structures, separating them from one another, but 
they will he seen to be directly continuous, and to be dissected 
off in one piece. 

Finally, we have Ellis's derivation from the recto-vcaical 
layer. This to my mind cannot be the case, for, as is indeed 
expressly stated by Quaiii, the fibres of origin of the levator 
aui muscle from the symphysis pubis are found distinctly 
between the recto-vesical fascia and the posterior layer of the 
iriaugular ligament. 




ABTEBO'POBTBKIOlt ViETICAL SEOIIOS THKOCOH TBI Bl-UIDEB AND 

B. Bladder. 
P. Prcwtata. 

H. MembranODB Drethra. 
p^p■ Fubo-proatetie ligaments. 

L, L. LtTAtor ani, nrifiiii; from tlio symphysis and pUrvd bi'tweea the 
, pubo-proatatic Usiamcnt (i.e. rtc to -vesical luai'ia, aod the poi- 
Mrior lajer of tlic triangular ligament). 

It is however a fact, that the rceto-vcsical fascia closes the 
pelvis above these attachments of the levator aui, between the 
anterior portions of the two white lines, except in the 
centre, where it dips down to join the prostate and the deep 
layer of the triangular ligament, leaving a small interval ; but 
this makes another layer closing the pelvis just below the 
symphysis, and we have, indeed, from without inwards : 

1. The superficial layer of the triangular ligament. 

3. The deep layer of the same, derived from the obturator 
fasciae. 

8. The recto-veiical fascia. 



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Triai^Iar lAgametit of the Urethra, 47 

And between the recto-reaical fascia and the triangular 
ligament a median septam w formed by the former dipping 
down in the centre to join the latter. On either side of this 
there is a little space, bounded above by the recto-vesicai 
fascia, below bjr the deep layer of the triangular ligament, and 
internally hj the median septum, externally by the obtnrator 
fascia covering the pabic bone, and in this the anterior fibres 
of the levator ani muscle run op to the symphysis. 

This may readily be demonstrated by carrying the ordinary 
dissection of the perinffium s little further. If the posterior 
layer of the triangular ligament, which is usually the deepest 
limit taken, be removed, this little space is opened up, and, 
from without inwards, first the levator ani muscle is met with, 
and deeper still the recto-vesicai fascia. 

Conversely, if a dissection be made similar to that indicated 
in the diagram. Fig. 1 j when the recto-vesicai fascia is re- 
moved the anterior fibres of the levator ani muscle st their 
attachment to the symphysis are exposed, and if these be then 
taken away, the posterior layer of the triangular ligament is 
uncovered. 

The above description is, in its essential details, just as it was 
written for another purpose some months ago. Since that 
time I have oonsulted Henle's ' Handbach der Anatomie,* 
vol. ii, part 1. The account of the triangnlar ligament, as 
given by this author, is different to that of English writers, 
for he describes the two layers, with the intervening muscles, 
as " the uro-genitttt diaphragm," which, on page 406, is stated 
to he " a partly aponeurotic partly muscular plate, stretched 
across between the lower mai^ns of both pubo-ischial bones." 

Again, on page 408, the muscular portion is stated to be the 
deep transverse muscle, and the two layers of tbe triangular 
ligament, one of which, of coarse, is above and the other below 
the muscle, are described as its upper and under fasciEe respec- 
tively, and not as a ligament at all. 

On page 6S5 we find that " the upper surface of the deep 
transverse mosde of the perinteum is covered with a layer of 
fascia, which bends upwards to the lateral borders in the 
obtnrator fascia, and passes towards the middle line on to tbe 
prostate, and from this to the sides of the urinary bladder." 

Now, Hfule calls i^ th« Aweitt oovering th« obtnrator 

D,91,zecl.yGOOg[e 



48 TVianffular lAgament of the Urethra, 

internuB mtucle obturator. Neverthelesa, it is, I think, evident 
from the drawing (fig. 432) that the portion alluded to in the 
above quotation is the part below what we know as the white 
linej and that, therefore, thus far his account agrees with mine. 
But he says also, it passes at the middle line to the prostate 
and urinary bladder, and again, in another place, " the upper 
layer (of fasds of deep tranarerae muscle) is on both Bides 
reflected from the pubea on to the prostate, and serves as a 
covering for the latter." Now, in my account I have said that 
the recto-vesical fascia dips doum in the median line in front to 
join the prostate and deep layer of the triangular ligament, 
and I think this is better than stating that the deep layer 
passes up to the prostate and urinary bladder, which is what in 
. effect, I believe, Henle says. A reference to his drawing (fig. 
403) will, I think, make this still more evident. 

Quoting further, on pi^s 525 and 526, we find: — "Between 
the wall of the pelvis and the bladder there is a deep, narrow 
depreseion, the floor of which forms the upper fascia of the 
deep transverse muscle. In this depression the levator ani 
runs backwards, with its lower border restii^ upon the upper 
fascia of the deep transv^se muscle, and with the lowest 
bundles of fibres arising from the foremost part of the same." 

Now, I believe this " deep, narrow depression " must be the 
little space I have described on either side between the recto- 
vesical fascia above and deep layer of the triangular lij^ment 
below, in which the levator ani muscle runs up to the sym- 
physis. Henle calls it " a depression " (literally a valley), but 
the anterior fibres of the levator ani are certsiuly separated 
from the pelvic cavity by the recto-vesical fascia, in addition 
to the floor being formed by the upper fascia of the deep 
transverse muscle. He should, therefore, I think, have added 
was a roof conatituted by the recto-vesical layer, 

I have quoted Henle thus Fully, because I believe that his 
account substantially agrees with what I have ventured to pat 
forward as the true one. Pevertheless, it is difficult to com- 
pare him with the English writers with regard to this struc- 
ture from want of uniformity in nomenclature and treatment, 
I am not sure, indeed, whether it may not be considered that 
my interpretation of his words is rather strained. One natu- 
rally wishes to have the confirmation of so distinguished an 



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Triangular Ligament of ike Urethra. 48 

anatomist; and, certaialy, if his text does not bear the con- 
itroction I have pat upon it, it is distiiictly at Tariance with 
the plate he givea to illnstrate the arrangement of the stmctnre 
I have been conrideriiig. The referenceB^ however, are pagea 
525 and 526. The drawing, fig. 402, page 625, and pages 
436 et teq. 

!Knally, I Gnd, also, that Godlee, in the text to part vi of 
his plates, makes the following statements (p. 220) : — " It 
(obturator fascia] is to some extent continnons along the arch 
of the pnbes with the posterior layer of the triangular liga- 
ment." And, again (p. 221) ; — " The posterior layer of the 
triangnlar ligament * * * * at its attachment to the pubic 
arch may be said to be continoous with the obturator fascia," 



oy Google 



D„t,M,Google 



RETLEX ACTION IN DIAGNOSIS. 



Bt p. ho&boces, md. 



Tauns part in an ordinary reflex action are the following : 

a, Stitnnlus. 

b. Peripheral termination of a Benaory nerve. 
e. Sensory or afferent nerve. 

i, GaaglioD centre. 

e. Motor or efferent nerve, vith its peripheral termination, 

/. Muscle or other irritable tissue. 

Paitictilar attention is called to the fact, that the muscle 
itself is a part of the reflex loop, and therefore, when no actioD 
results from a attmnlns, which usually produces an action, the 
ledon may be in any part of the loop, including the muacle. 

The visible, palpable muscular action itself, normally produced 
by stimvli, may be diminished or increased, or there may 
he no action at all to any stimulus, or there may be no action 
to oertain atimnli, and greater or less action than normal to 
oUter atimnli. 

Phyaiologiata tell us that a reflex act ia influenced by the 
intmdty, nnmlier, and duration of the stimuli applied to the 
aanaory nervea j and, as a rule, the resulting movement is more 
complex when the stimulus is applied to the peripheral nerve 
endings thsn to the nerve trunk, Practically, only the former 
an i^nnlated by the physioiaa for the purpose of diagnosis. 

D,o-z?c.,,Gooj^lf 



52 Reflex Action in DtagnaHa. 

The stimuli are under his control. He can apply one or 
more of them in any quantity and for an; length of time. No 
other part of the r'efles process can be influenced in this ^kj, 
altboughj as will be mentioned further on, he may modify 
certain other parts indirectly. If, then, a certain definite sti- 
mnlufl be used, and applied for a given time to a certain part on 
one side of the body and then on the other, and the resulting 
actions be compared, any difference observable between the 
two mast depend upon a difference somenhere in the reflex 
loop involved. Again, when it can be stated that, in a normal 




Fib. 1.— SsOTioir bhowiko Lbft Ham or SpnrAn Cord. 
From fbe anterior coran \» seeo coming off an efferent motor nt 



(«■•), pMwng 
tliepo*teriorc( 



I to » muscle (II). From gkin (S) ii aeen atcending to 
I afferent laniory nerve (a i), w!th the gangUon (O). 



state of health a certain stimulus, applied to a certain part, will 
produce a certain action, then, if such action do not result in 
a patient, or if it be diminished, or sluggish, or exaggerated, it 
may also be asserted that the reflex loop is affected in some 
way. Nevertheless, it must be remembered that persons difier 
widely in reflex irritability, that in children it is' greater than in 
adults, probably because in them the brain is not so highly 
developed, and so the reflex actions in the spinal cord are not 
so mnch under control ; also, that conditions of the skin and 
superficial fascia, such as a thick skin, a large quantity of adipose 



„Gooj^lc 



Refiex Action m Diagnotia. 53 

tissue, cedema, &c., may greatly modify reflex actions vithoat 
any real disease in the reflex loop, beyond sucli physical inter- 
ference with the ends of the sensory nerves as would be canted 
by the above. 

la the annexed diagram (Fig. 1] are seen the various parts 
entering into the reflex loop. The afferent sensory nerve 
passes through the posterior root into the posterior grey 
eoma, or into the lateral column in its immediate neighbour- 
hood, whilst the eflTerent motor nerve is issuing from the ante- 
rior grey comn and passes through the anterior root, and then 
onto the muscle. It will be noticed that the motor and sensory 
nerves run close together to their destinations ; and, as a matter 
of fact, they are generally bound up together so as to form one 
nerve apparently, as in most of the spinal nerves. But this is 
not at all essential ; they may run quite separately, as in most 
of the cranial nerves, and even in the spinal nerves, where they 
run together, they are perfectly distinct, never anastomosing 
together. Theoretically the reflex loop may be affected at any 
part, and hence we might hare lesions of: 

1. Peripheral endings of sensory nerves. 

2. Sensory nerves (including posterior roots). 

r Anterior comn a. 
8. Q-rey matter of cord \ Posterior comua. 

L Portion between these two. 

4. Motor nerves (including anterior roots). 

5. Peripheral en^gs of motor nerves. 

6. Muscles. 

And again, the grey matter of the cord may be influenced by 
disease in any part of the white matter of the cord ; that is, the 
posterior, lateral, or anterior. 

It mast also be remembered that a ganglion centre which is 
receiving sensory impressions, is not so readily traversed by 
another sensory impression arriving from another part. A 
person, for instance, under great mental excitement or pain might 
have his ordinary reflexes abolished ; and thus may be explained, 
what has been noticed a great many times, that soldiers in battle 
may receive blows and wounds of which they are entirely igno- 
rant until after the battle, the stimuli having neither reached 
the higher perceptive faculties, nor produced the ordinary 
reflex lesulto. 

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54 R^x AeiUm in DiagnosU. 

EzperimeDtally, in animals, any one of the six parts of ihe 
reflex loop above enumerated can be irritated or destroyed j and 
practically, one meets witli iDstances of lesions of each, except^ 
perhaps, the peripheral terminations of motor nerves ; and, per- 
haps, as pathology advances, snch lesions may be found. Thus 
we get lesions of the peripheral ending of the optic nerve in 
retiual disease ; of sensory nerves, a> in tumours of the diCTerent 
trunks of the fifth ; of the grey matter of the cord, as in anterior 
and posterior comual myelitis j of motor nerves, as in facial 
paralysis ; of muscles, as in inflammation of muscle, flabbineaa 
due to generally weak conditions of the system, &c. 

Experimentaily the motorial end plates can be paralysed by 
curare. 



1. 8Hn mtd mueout memtranet. 

The ordinary stimnli applied to these parts give rise by 
reflex action to certain movements. Thus, tickling the solra 
of the feet causes drawing up of the lower extremities. A 
scratch on the inner side of the thigh prodncei contraction of 
the cremaster musole. A scratch from the last rib to the 
anterior superior spine of the ilium causes contraction near the 
umbilicus, and one from the nipple to the hypochondrium 
causes a movement in the epigastrium. Similarly scratches 
in varions other regions cause contractions tn those parts 
severally. In the mucous membranes the reflexes are much 
more complex. Thus, tickling the back of the fauces oawes 
vomiting, tickling any part of the larynx cantes coughing, 
tickling the nasal mucous membrane causes sneezing. These 
reflexes have been described as superflcial reflexes in con- 
tradistinction to the so-called deep refleocea (Qowera), but 
inasmuch as the latter are probably not reflex, the term 
" cutaneous reflex " is preferable, or if " superGdal reflex " be 
retained, it must be taken as meaning that the stimnli an 
applied to superficial portions. 

From the above the following names will be easily comiw»- 
bended : 

Plantar reflex. 

Cremaster „ 



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R^fiex Action m DiagnotU. S5 

Abdommal reflex. 

Epigastric „ 

OlDteal „ 

Lombar „ 

Dorsal „ 

Scapnlar „ 

Palmar „ 

Conjanetivsl „ 

Phiwyiigeal „ (retching). 

laryngeal „ (coogliing). 

Nasal „ (sQeeziiig). 

In obtaining these cutaneous reflexes, it is best to pass the tip 
of the Gnger, or the point of a quill pen, rapidly and lightly over 
a rather large Borface, so as to stimulate quickly and nearly 
umnltaneonsly a great many endings of a nerve. In children 
it is better to use the finger than a pen, esperaally in getting 
the cremaster reflex, for if present, it is most easily obtained 
in thia way, and they cry if scratched with a pen. 

The first four in the above list, and the conjunctival reflex, 
are the most oseftil in diagnosis. For they are, as a rule, 
present in normal individuals and are more easily observed than 
the rest. 

Mention baa been made of the fact that the centres in the 
spinal cord are in communicatiou vrith the higher cerebral and 
cerebellar centres. "When these are cut ofi^, as by section 
through the spinal cord, the cutaneous reflexes below the section 
are increased. Thus, a man fractures his apiue and injures the 
spinal cord, say in the dorsal region ; tickling the soles of his 
fbet produces mach more violent movements of the lower ex- 
tremities than under normal conditions; and it is on this 
account that the brain is said to inhibit the reflex action of the 
spinal cord. In animalB, when the cord is cut, the reflexes 
below are abolished for a time, apparently from the shock of 
the operation; bnt after a certain period of time, which is very 
short in &ogs, but some weeks in dogs, the reflexes are much 
more violent than is normal. Similarly in fracture of the spine 
the {dantar reflex may not be increased for some weeks. 

^e reflexes may be increased in disease, as in tetanus, where 
the slightest stimulus produces general contractions, the ap- 
parent impalae flowing readily into the various x^otQT chaoDeU ; 



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66 Reflex Action in IHagnosia. 

and in poisoning by stt7ohni&, where the same reflex iirita- 
bili^ IB seen. 

These cntaneons reflections are not altered in : — 

Meningitis. 

Paralysis agitans. 

Hydrocephalus. 

Chorea. 

Epilepsy. 

Hysteria. 

I have tested them in all these diseases^ and they hare 
inYariably been present, except, perhaps, the cremaster reflex, 
which has sometimes been absent in adults with a very loose 
and long scrotum. 

It is to be observed that in none of the abore diseases, so fitr 
as is known of their pathology, is the reflex loop afl'ected, nor the 
cerebral connection of the cord interfered with. Nevertheless, 
it is possible that, hereafter, cases of hysteria may be found in 
which the cutaneous reflexes are altered. I have not yet had 
an opportunity of testing them in a case of psendo-bypertrophic 
paralysis, and have not been able to flnd any obserratioua on 
the point ; they would probably be absent, at least in the parts 
affected, seeing that the muscles become practically destroyed. 

If cutting off the higher cerebral centres causes an increase 
in the reflex phenomena of the cord below, we should expect 
the cutaneous reflexes to be increased, not only in fracture of 
the spine, but also in 

Transverse mjeiitis. 

Pott's disease. 

Growths. 

Qummata, &c. 

No doubt this would be the case if it were not that descend- 
ing lesiocB are so rapidly induced, which lesions modify the 
reflexes. 

It is a remarkable feet that the cutaneous reflexes are 
diminished on the paralysed side in hemiplegia due to cerebral 
origin, and not so when the paralysis is due to a lesion in the 
cord. Dr. Gowers suggests the ingenious theory that it is due 
to a cutting off of a centre in the cortex of the brain which 
normally inhibits an infaibiting centre in the optic thalamus. 
The fact may be of use in diagnosUi though all the cases that 



Google 



Refiex Action in Diagnoait. 67 

bave yet come under my own observation were easily diagnosed 
H cerebral, qnite apart &om the reflexes. 

The cutaneona reflexes are also diminisbed in 

Infantile paralysis (e.g. plantar reflex abolished when the leg 
is affected). 

General spinal paralysis. 

Frt^ressiTe mnacular atrophy. 

Tabes dorsalis. 

Local myelitis. 

Lesions of motor or sensory nerves. 

In the first three there is not only a lesion in the reflex 
loop (in the anterior boms of the cord), but also a wasting of 
the muscles which perform the act. 

In tabes dorsalis these reflexes are not aflPected at flrst but 
only after the disease has made some progress. The plantar 
reflex is one of the first to disappear, and there is, as a rule, a 
connderable amount of ansstbeaia. This is probably dne to 
the fact that the posterior roots are involved in the sclerosis 
which constitntes thiis disease. Bat it most be remembered 
that anwsthesia may be doe to a lesion in a part of the spinal 
cord above, is which case the cntaneous reflexes below would 
be increased; in other words, it most not be assumed that 
where there is loss of sensation there is also an absence of the 
cutaneons reflexes. 

The cremaster reflex is the next to disappear, but for a long 
time, and it may be to the end, none of the rest disappear, 
probably because the sclerosis is not wide enough, and so 
the reflex loop is not affected, except in the lumbar part of the 
cord. 

In local myelitis the cutaneons reflex, having its centre in 
the aflTected part of the cord, is abolished. Those below it are 
increased, and those above it remain normal. 

In lesions of sensory nerves there is ansesthesia as well but 
no paralysis, whilst in lesions of motor nerves there is paralysis 
but no aassthesia. Lesions of mixed nerves produce both 
paralysis and anjestbesia. 

As an example of absence of reflex in lesions of sensory 
nerves may be taken affections of the fifth nerve. Irritation 
of the conjunctiva no longer produces contraction of the orbi- 
cularis palpebrarum ; at the same time there is dnssthesia of 



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68 Reflex Aciiett in Diagnotit. 

the face, Again^ the lesion of a motor aerve is illastrated 
by facial paralysis, in which irritation of the conjanctiTa 
produces no action because the orbicularis palpebranun is 
paralysed, along with all the other facial muscles. 

It is said that sexual power variei pari pattu with the 
cremaster reflex. This is verified in many cases of locomotor 
ataxy, where complete absence of the cremaster reflex is acoom- 
pRQied by complete absence of sexnal appetite. Whilst in 
certain other cases where it is increased there is an admitted 
increase in the sexual desire. It is not, however, always the case. 

Patients will be met with having almost complete loss of 
sexual desire and power (the desire generally fails a consider- 
able time before the power), whilst the cremaster reflex ia 
normal ; and it is not uncommon to find the latter absent with 
no change in the sexual fonctions. 

It is a difficult matter to explain why, in certain caaea, the 
so-called deep reflexes are increased and the cutaneous reflexes 
diminished. But, as will be described further on, the ftH-mer 
are in all probability not true reflex phenomena, though depend- 
ing on the integrity of the reflex loop for their production, 
whilst the latter are certainly truly reflex, inasmuch as the 
resulting muscular action maybe quite removed from the seat of 
irritation ; thus, tickling the soles of the feet causes contractioa 
of the thigh muscles ; stroking the middle of the upper part of 
the thigh causes contraction of the cremaster. In both of these 
cases the muscular fibres are not directly irritated, nor are their 
tendons at all pulled upon. It is possible also that the reflex 
loop between skin, cord, and muscle, is not the same as that 
involved in the so-called deep reflexes, which, as will be 
presently mentioned, is probably from muscle to cord, and 
thence by motor nerves to muscle again. 



2. Mutcles, tendoru, ^e. 

If, with one leg crossed over the other the ligamentum patelbe 
be struck with the side of the extended hand, the foot is kicked 
out involuntarily. This occurs in almost every one. 

A few years ago Westphal, of Berlin, pointed ont that this 
action could not be obtained in locomotor ataxy. Almost at the 



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Reflex Action in Diagnorii. 59 

same time Erb wrote npoo the same subject, and deHribed the 
narmal phenomenun as the " patellar-tendon reflex," belienng 
it to be a reflei act. Westphal called it the "knee phe- 
nomenon/' and did not think it to be troly reflex, bot to reaolt 
from an irritation of the mnscalar fibres, dne to the puU on the 
tendon caused by the blow upon it. 

Dr. Qrainger Stewart and Dr. Buzzard were the first to 
describe it in this country, and they took Erb's view of the case, 
namely, that it is a reflex phenomenon. 

Westphal then pointed ont that if it was reflex the afferent 
nerves conld not be cutaneoas (patellar plexosj nerves ; for, not 
the (lightest action can be obtained by any amount of pricking 
or otherwise irritating the skin, or percussing it when pinched up 
in a fold. The afferent fibres were then said to be in the tendon 
itsel£ This, however, has been disproved, at least in the tendo- 
Achillis, by Dr. Oowen in his work on the * Diagnosis of Diseases 
of the Spinal Cord,' It must be mentioned that if the tendo* 
Achillis be struck, a contraction of the gaatrocnemins results, 
jost like that of the qnadrioeps extensor when the ligamentnm 
patelln is strook. " While a lateral tap on the tendon (tendo- 
Achillis) vrill cause the oontrsctionj if the other edge of the 
tendon is so supported that the tendon cannot move under the 
tap, and so cannot affect the muscle, no contraction occnra." 
This proves that the afferent nerves are not those in the tendon. 

Another important fact confirming the same thing is, that 
no other kind of stimulus, electrical, chemical, or thermal, 
applied to the tendon, will causa a contraction of the muscle. 

The next supposition by the reflex theorists was, that the 
afferent nerves are in the muscle itself (tee dotted line in fig, 
2), and that the blow on the tendon, by pulling upon these 
nervea, ori^nates a atimnlua in them which passes up to the 
spinal cord, along the sensory tract, and therefore throngh the 
posterior roots, and thence from the spinal oord along the 
motor nerve to the muscle, 

Tscbiriew then pointed ont that the time between the blow on 
the tendon and- the resulting contraction was much too short 
(only '03 of a second) for it to be a reflex act, according to the 
known rate at which nerve impolies travel. Dr. Gowen also 
pointed out that the time in the closely allied ankle clonus, 
which will be described presently, was mnch too short (or that 

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60 Reflex Action in Dtaffnosis. 

to be truly reflex, and quite receDtly Dr. Waller* has con- 
firmed Tschiriew ae to the shortness of time in the productioD 
of the knee phenomena, and has made the imporLant observation 
that the actual time taken to produce contraction of a muscle 
is exactly the same (viz. *035 sec.) in 

(a). Percussing its tendon. 

(£]. Fercu»siDg ita muscular fibres. 

These facts seem fatal to the reflex theory, unless it be 
assumed that the rate of nervous impulse is much quicker than 
physiologists have yet made out. But besides the refiex theory 
there is another, which may possibly be the correct one. I 
will designate this the " tonic theory." 

Normally muscles are in a state of slight contraction, vbich 
physiologists call tone. And this tone depends for its existence 
not only upon a healthy condition of the muscles themselves, but 
also upon a healthy condition of some reflex loop, between 
either skin, cord, and muscle, or tendon, cord, and muscle, or 
muscle, cord, and muscle (vide Fig. 2). 

Whatever be the reflex loop, it is quite certain that, whenever 
it is cut, the muscle losra its tone. Brondgeest, Cyon, and 
others, hare shown that when the sensory nerves of a part, or 
the posterior roots (also sensory)^ are cut, the corresponding 
muscles lose their tone. 

When the spinal cord is destroyed and broken up the muacles 
lose their tone, as can be easily demonstrated by passing a wire 
down the spinal canal of a frog and breaking up the cord, and, 
as is constantly seen in cases of acute myelitis, which destroys 
the cord, so far as the reflex loop is concerned. Again, when 
the motor nerve is cut or diseased, the muscles lose their tone ; 
e.ff. in facial paralysis due to inflammation about the stylo- 
mastoid foramen, the muscles of the aflected side lose tone and 
therefore drop, the healthy side appearing to be drawn up. 
Lastly, if the peripheral ends of the motor nerves be paralysed 
by curare, the muscles become perfectly flaccid and toneless. 
So that both experiment and disease declare that, whenever and 
wherever the reflex loop is destroyed, the muscles lose their 
tone and become flaccid. 

One can also make the converse statement " that whenever 
a muscle has lost its 'tone' the reflex loop is somewhere 
1 ' Unin; put r, Jnljr. 18S0, p. ITS, 

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Reflex Action in Diagnotit. CI 

affected," if the mascniar fibres which may lose their tone from 
disease in themselves, or from ezfaaaationi be ODderstood to 
form part of the reflex loop. 

A blow on the tendon of a mascle will increase the tension 
in that tendon, and as a consequence poll upon the muscular 
fibres above ; and if these muscular fibres be in a state of slight 
tension, i.e. tone, before the pnll, then they will contract npon 
the additional tension being applied, bat if they be flaccid, the 
additional tenuon is not sufficient to irritate them into a con- 
tntndoii. 

Dr. Buzzard pointed out, however, that in locomotor ataxy, 
whilst there was cximplete absence of oontractioD in the quadri- 
ceps on percussing its tendon, yet on percossing its muscular 
fibres directly it contracted as well and often more readily 
than is normal. This I have confirmed in several cases. There 
is, however, a difference between a direct blow on the belly of a 
muscle and a pull upon those fibres from the tendon below. 

I have searched in works on physiology to see if a pull on 
the tendon is one of the ways in which a muscle can be made 
to contracit, but can find no allusion to it. So I made the fol> 
lowing experiments, assisted by my friend Mr. J, H. Barnard ; 

Experiment 1. — A &(^ was pithed, and then one of its 
muscles removed, together with the piece of bone iiom which it 
took its origin ; the bone was then fixed to a peg and the tendon 
pulled over a small iron bar and a weight hung to the end of 
it by means of a piece of silk tied round the tendon. Letting 
fall the w^ht or pulling npon it in any way failed to produce 
the least effect, altiiongh the muscle was in a perfectly healthy 
and irritable condition, as was shown by the ready contracttons 
produced by slight blows on the fleshy muscular fibres. 

The experiment was varied by suspending the muscle 
perpendicularly and palling npon the tendon below. There 
was not the stightest response. Of coarse the muscle being 
removed from the body was quite flaccid and toneless. 

Experiment 2. — The same muscle was exposed in the opposite 
limb, and its tendon of insertion separated so that a silk thread 
could be passed round it. Mone of the nerves were interfered 
with, nor the spinal cord, beyond the pithing above. So that 
the muscle was in a normal state of tone, and the reflex loops 
intact. The limb was then placed over a bar so as to hang 

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62 R^x Jetton in Diagnont, 

perpendicnlftrly, the body of the frog being supported on a tahle. 
A pull upon the tendon, or simply hanging 8 weight npon the 
thread attached to the tendon, readily oaased contraction in the 
mnscle. 

1!ha first of these experiments shows clearly that a poll on 
tiie moscolar fibres from the tendon below will not cause 
contraction in a mnscle, whilst a blow on the fibres themselves 
will do 80. I do not know of any explanation of it, becanse it 
is clear that the poll must irritate the mnscalar fibres, in some 
degree at least. 

Seeing that the reflex loop had to be left intact in the second 
experiment, it may be said that the puU on the tendon caosed 
a contraction in the muscle, not by irritating the fibres directly, 
but by irritating afi'erent nerves, the stimuluB passing up to the 
cord and down the efferent nerves by reflex action. But I would 
ask die reflex theorists, why the pull on the tendon below will 
not set up contraction in a muscle romoved from the body, or 
one whose reflex loop is destroyed. The fibres mnst be pulled 
upon, and they are irritable to direct percussion. But it is 
clear that a direct blow is very different from an indirect pull. 

That the absence of contraction upon striking the tendon of 
a mnscle is due to lus of tone in that mnscle is true, I believe, 
for the following reasons : 

1, It is absent when the afferent nerves to a part are cnt. 
Brondgeest has shown that, under this condition, the mnscle 
has lost its tone. 

3. It is absent in locomotor ataxy, where the posterior root 
sones are affected. 

Debove and Bondet have shown that there is always loss of 
tone in the quadriceps and various other muscles in tabes. 

8. It is absent iu all cases of anterior comnal myelitis 
(infantile paralysis, adult spinal paralysis, &c.), and in all of 
them there is loss of tone. 

4. It is diminished or absent when the muscles themselves 
a» partially or completely toneless, either from excessive use, 
or disease iu themselves. 

This I have proved iu myself after a long walk ; and indeed 
there is less response at night after a day's work than in the 



BioM the above was written I have bean pleased to see an 

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Rtfie* Action in Diagno$it. 68 

obBemtioii,mKleb;Westphal, id the 'fieriiner Klin. Wochen- 
schrift/ Jul. Srd, 1881, which is confirmatory of my Btatement. 
It is that the knee phenomenon is wholly alwent juat after an 
epileptic fit. It is obvioiu that daring the fit the muBcles are 
moot powerMly contracted, both daring the tonic and clonic 
■tate ; and hence they become tired oat, and relax into tone- 
leBsneu, and bo the tendo-muscolar phenomenon ia absent.^ 
Bnt the mnsdes soon Tecover,and hence the normal phenomenon 
speedily resppeare. Dr. Qowers tells me it is absent for thirty 
seconds only. 

It is int««sting also to observe that in most of the cases 
published by Dr. Gowers in which the knee phenomenon could 
not be obtained, quite apart from any spinal disease, the patients 
were bad walkers, prolnbly becanse their mnscles were easily 
ezhansted. 

5. If an animal be cararised and pithed, all its motor nerves 
are paralysed at the peripheral extremities, and the mnscles lose 
tone. 

I have done this with the assistance of my friend Mr. 
Barnard, and we found complete absence of the tendo-mnscnlar 
phenomena. 

It is obrions, howerer, that none of the above reasons disprove 
the reflex theory, indeed, they might equally be used as argu- 
ments in its &Toar. For if this theory be true it is obvious 
that a lesion of any part of the loop will cause the disappearance 
of the phenomenon. And again, in those cases where the 
muscle itself has become flabby from overwork, walking, 
einlepsy, %m., the reflex theorists might say, that of coarse no 
contraction will result, no matter what stimulus passes round 
the loop, if the moving portion, i.e. the muscle, be from any 
cause rendered useless. At the same time, one would have 
thought that if the stimulus be greatly increased it might be 
able to whip np a flagging muscle to contraction. 

Bot every tittle of evidence brought thus far in favour of the 
reflex theory is equally in favour of the tonic theory, and vieo 
vend; and there then remain these facts which, to me at 
least, seem to turn the scale in favour of the latter. 

6. The time is much too short for it to be reflex, whilst it is 
' Tke fit miut 1m s HT«n one with grest itraggUng, or elw the phonomeoon li 

aotsfasnt. 

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64 Reflex Action in Diagwni*. 

exactly what one would expect, if the contraclion of the muscle 
were due to the direct irritatiou of the fibres by the pull od the 
tendon. 

7. The actual time tnken to produce contraction of a mascle 
is, as has been alreadj> ineutiaued, exactly the same in : 

a. Percussing its tendon. 

b. Percussing its muscular fibres (Waller). 

But, whichever theory be true, the nsefulness of the pheno- 
mena in diagnosis is in no wise impaired ; for inasmuch as the 
absence or exaggeration of the contraction is in nearly all cases 
due to an alteration in the muscle produced by a lesion iu the 
reflex loop, one caa readily diagnose such a lesion to be present. 

These tendo-muscular phenomena are found normally in all 
the muscles in the body whose tendons are, under the necessary 
conditions, that is, capable of being percussed or pulled or 
otherwise stimulated, so as to increase their tension. Hence 
we find the best examples in the quadriceps extensor with its 
ligsmentnm patelln ; the gastrocnemius and soleos with the 
tendo Achillis ; the triceps with its tendinous insertion into the 
olecranon. If the outer side of the back of the wrist be per- 
cnssed, there is sometimes a direct flexion of the forearm on the 
arm, which is due to contraction of the biceps, set np by the 
pull on its tendon where it is inserted into the tuberosity of the 
radius, besides which there may be an extension of the hand 
from contraction of some of the extensors. 

Other muscles are not so readily excited, but the zygomatic 
muscles and others around the mouth may be made to contract 
by percussing their tendinous attachments (malar bone, jaw, 
&c.). Hence we may speak of these phenomena as — ~ 

a. Knee phenomenon . 

b. Ankle phenomenon. 

c. Elbow phenomenon. 

d. Wrist phenomenon. 

e. Zygomatic, and other phenomena.' 

The knee phenomenon is said to be absent in normal indi- 
viduals in one per cent. (Berger). Westphal, however, has 
never yet met with a case, and out of more than 200 

' Sinm the ftbove wm written Dr. Qowcn has propowd the general term 
" mjobltic contractioD " (rarwdt, itnitcbed), one of the euentul couditioaa bong 
e certain degree of tenrion in the muicie. 



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Reflex Actum in Diagnotit. 65 

cues ID which I have tried it, it waa only absent ia tfaoae who 
were very fat, and whose ligamentam pateUn could not be 
properly got at ; and in most of those cbbcb no action could be 
obtain^ on direct percnssion over the belly of the muAcle itself, 
thesame condition being present, i.e. a thick layer of fat, I may 
also state that it ia exceedingly difficnlt to obtain the phe- 
nomenon in some people, who are wholly unable to relax their 
muscles nfficiently, for any voluntary contraction at once stops 
the phenomenon. By far the best plan of obtaiDing it, and in 
no case ought the phenomenon to be called absent unless it be 
adopted, is to hare the patient seated on a high table, with 
boots, stockings, and trousers off, and the legs hanging loosely 
down. Several times I have got it in this way when both 
others and myself were unable to obtain it in any other. 

The amount of contraction in the muscle, and therefore the 
height to which the point of the toe rises, varies in different 
people. 

The ankle phenomeDOD, i.e. contraction of the gastrocnemius 
sod solens on percussion of the tendo-Achillis whilst the leg 
ia supported anteriorly near the foot, and flexed so as to he at 
right angles to the thigh, has been present in every normal 
individtud in whom I have tried it (more than 200 of various 
ages). It is very readily obtained, even with the boot on. 

Tlie elbow phenomenon is also normal, and of 300 consecutive 
cace%that I have tested, it was only absent in one, a man over 
six feet in height, and with very powerful and thick muscles, 
who could not be got to hold his arm in proper position and 
relax his muscles. 

This phenomenon is obtained by pulling the arm a little 
away from the body, the physician standing behind the patient, 
placing his left hand under the lower end of the humerus and 
raising it to a horizontal position, letting the forearm hang 
vertically and quite loosely. Then the tendon of insertion of 
the triceps is stmck jost above the olecranon. As this tendon 
is very short, great care mast be taken not to strike the belly 
of the masde, because that will produce a contraction even 
when the tendo-muscular phenomenon is absent. 

The wrist phenomenon is obtuned by holding the lower end 
of the forearm in one hand, with the elbow bent at an angle of 
about 95°, and the hand hanging quite loosely, then striking 
vol., XXV, 6 

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66 Reflex Action im Dioffnosis. 

the tendon of the extensor on the radial aide of the wrist. The 
biceps contracts and caasei flexion of the forearm on the arm, 
and sometimes the extensors contract and cause extenaloii of 
the hand. ' 

The wrist phenomenon is much more often absent than 
present. In the cases (more than 200) in which I tried it, it was 
present in twenty, most of whom were young women* Dr. 
Buzzard tells me he has found it in much older people also, both 
men and women. Its absence, however, does not mean any- 
thing, but when exaggerated it is often useful, more especially 
as it can be so easily tried. 

The reactions of the zygomatic and other muscles are not of 
ao much value. They are, as a rule, present normally, bat are 
very different in different indiriduals. 

These tendo-mascnlar phenomena may be : 

1. Absent. 

2. Exaggerated. 

1, They are absent in the following diseases : 

r Posterior root zones and sensonr 
o. Locomotor .tay| „„t. »l«OBed. 

b. Infantile paralysis. -^ In all these 

c. Adult spinal paralysis. I there is 

d. General spinal paralysis. > anterior 

e. Fn^^Bsire muscular atrophy (some I comnal 

cases). J myelitis. 

/. Diphtheritic paralysis (Ord), pathology unknown. 

rDiBease in mnscle. It 
g, Pseado-hypertrophic J will probably be found 
paralysis. | absentinother diseases 

L of muscle. 
r One case recorded by West- 
A. Gteneral paralysis of the J phal. There was solero- 
insane. ] sis of the poBteriw root 

L zones, bat no ataxia, 
t. Lesions of sensory nerves. 
j. Leuons of motor nerves. 

k. Loss of tone in the muscle irom any other cansei 
such as fatigue or overwork. It is for this reason, 
I believe, that it is absent just after an epileptic 
fit ; and if the reaaon I have given be correct^ it 



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Refiex Action in Diagnotit. 67 

will be found absent after any severe convulsion, 
wbateyer be the caaae of the fit. Poisoning by 
curare completely abolishes the phenomenon. 
The accompanying diagram shows the varions parts of the 
coid which are affected in different diseases producing altera- 
tions in tendo-muscnlar phenomena. 

The posterior root zones are affected in tabes ; and in West- 
pbal's case of general paralysis of the insane without tabetic 
symptoms the same parts were affected. 




Fia. 8. — Sacnov tbbouoh Stikal Cobd, HBownra Fibts atibotiii 

in TABIOOB DiBBABU. 

1. Anterior cornn. (lofsQtile paraljais, &<!.) 

B. Foaterior lOOt tone. (Looomotor aUxj.) 

S. Crooed pynmid«l tract in lateral colamn. \ DMoandiag U- 

4 Direct pjTamidal tract in anterior median colnmn. J tcral icleroeia. 

C. ForterioT median oolnmn. (Atcmding ideroaii.) 
Tbea&rent Motors nerve i* represented bolov anunglKNU the three 

different p«rts, skin, tendon, and moscle, S r, T z, m x (dotted line), 
respeetivdf. 

The anterior boms or comna are affected in four diseases, 
in&otile paralysis, Sw. The muscle itself is affected inpseudo' 
hypertrophic paralysis, eshaustion, 8w. 

In all the above there is an absence of the phenomena. 
Presently, diseases will be deacribed in which they ure increased, 



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68 Reflex Aclion in Diagnosis. 

and in these the lateral colamna will be found affected as 
shovn in the diagram. And when the descending sclerosis is 
due to some lesion in the brain, it will be fonnd that degene- 
ration has taken place not only in the lateral column of the 
opposite side, corresponding to the fibres which cross over be- 
tween the pyramid of the medulla oblongata and therefore called 
the " crossed pyramidal tract," but also in the anterior median 
colamns of the same side as the lesion, in fibres which do not 
cross at the anterior pyramids and so called the " direct pyra- 
midal tract." When sensory nerves are cut, the posterior 
median columns degenerate from below upwards ; but the parts 
corresponding to the cord thus sclerosed are not affected as 
to the tendo-museular phenomena. 

The absence of the knee phenomenon in locomotor ataxia is 
one of the very earliest symptoms of that disease, and is 
often of service in diagnosis. Cases said to have been tabes 
have been recorded in which, so far from the knee phenomenon 
beiug absent, it has been exaggerated, Westphal says he has 
never met with such a case, and throws doubt on the diagnosis 
of those published. Of course there may be a stage in tabes 
antecedent to that in which the kuee phenomenon is absent, 
bnt if there is it is so early, that there would be none of the 
other symptoms present, inco- ordination, shooting pains, 
amaurosis, small and often unequal pupils, which do not react 
to light, but contract on accommodation, &g. 

The early failure of the knee phenomenon suggests that when- 
ever a patient compltuns of defect of vision, or when his pupils 
are seen to be small, &c., tabes should be suspected, and the knee 
at once tested. If there is no reaction the disease is in all pro- 
bability tabes. In diseases with subjective sensations which 
might give rise to suspicious of tabes, the presence of the knee 
phenomenon might decide the diagnosis. 

From the foregoing remarks on the cause of the absence of 
the tendo- muscular phenomenon one can easily see its appli- 
cation in tabes. In this disease there is a chronic inflammation 
going on in the outer portion of the posterior columns of the 
spinal cord, abutting upon and at last involving the posterior 
grey horns and the posterior (sensory) rootsjustas they enter the 
cord. Chronic interstitial inflammation of the cord (sclerosis) 
is comparable with cirrhosis of the liver or granular kidney. The 



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Reflex Action in Diagnoiit, 69 

part affected becomes harder than normal, and its proper tissue 
elements are destroyed and replaced by a fibroid tissue. In this 
way the reflex loop is destroyed at this portion of the cord. 
There is, as a consequence, a loss of tone in the muscles corre- 
Bponding to the part affected, and there is also an absence of 
ibe teodo-moscular phenomenon. 

Debore and Bondet, in the ' Archives de Neurologie,' hare 
shown by means of an instrument called the myophone, for 
measuring the tone of a muscle, that there is diminished tone 
in groups of muscles in locomotor ataxy and always in the 
quadriceps extensor. They very ingeniously account for the 
inco-ordination in this disease. They say that it requires more 
■timnlus to cause an atonic muscle to act than a healthy one 
with tone, and that the volnntary stimuli sent down to the 
muscles of the extremities in ataxics, cause some muscles 
(tonic) to contract before others (atonic) ; hence the unsteadi- 
nen. There is an attempt to correct this by a maximam con- 
traction of all the muscles involved, and hence the exaggerated 
moscnlar action, so characteristic of this disease. 

The disease niay affect any portion of the spinal cord^ but 
for some hitherto unexplained reason it affects chiefly the 
lower part, and gradually diminishes towards the upper part. 
One finds, therefore, that in all cases the knee phenomenon and 
the ankle phenomenon (not ankle clonus, but contraction of the 
gastrocnemius to a blov on the tendo Achillis], are quite 
absent, whilst the elbow phenomenon is seldom absent. 

The following is a case in point, and is interesting also, 
inasmuch as it is a case of locomotor ataxy in a woman, which 
is not very common. 

Mary Ann D — , set. 67, came under my care at the National 
Hospital for the Paralysed and Epileptic on the 18th October, 
1880. For the last two or three years she had had shooting 
pains and soreness in the epigastrium, which had become much 
more severe the last few months. Then she found difficulty in 
walking about in the dark, and now can scarcely get along in 
the daytime. 

Her gait as she entered the room was typically ataxic, and 
on examination it was found that she had numbness and anffis> 
thesia over the front part of both legs and over both thighs 
(superficial to the quadriceps). No anesthesia in th? upper 



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70 Reflex Action in Diagnosis. 

extremities, and no shooting pains, and no inco-ordinatioD in 
them. Complete absence of knee and ankle phenomena. Elbow 
phenomenon present. She had also dimness of vision and 
small pupils, which did not contract in the least to light, bat a 
little to accommodation. 

But the elbow phenomenon may be absent in locomotor 
ataxia, as the following case sboffe : 

Thomas S — , set. 40, came under my care at the National 
Hospital on the 28th of May, 1880. Has suffered for sis or 
eight years with shooting pains and difficulty in walking, more 
especifdly in the dark. Has had syphilis. 

Present condition. — Extreme form of ataxic gait. Cannot 
get along at all without assistance, and throws his legs about 
with great violence. Much difficulty in keeping upright. 
Considerable antesthesia of feet, legs, and thighs, and also of 
arms, especially in the distribution of the ulnar nerre. Slight 
in CO -ordination in upper extremities, as shown by the fact that 
he is unable to touch the end of his nose quickly. He nearly 
always misses it, and sometimes touches the malar bone or the 
lip. Pupils equal, do not contract to light, but slightly to 
accommodation. 

Total absence of knee, ankle, and elbow phenomena. 
Direct percussion on the quadriceps, gastrocnemius, or 
triceps, causes contraction in each. 

In all probability the posterior sclerosis has ascended as high 
as the cervical portion of the spinal cord, and thus is affecting 
his npper limbs. 

In infantile paralysis the tendo-muscular phenomena are 
absent in the paralysed parts. This may be of use in diagnosis, 
I have Seen a case in which the upper and lower extremities of 
one side were involved, and which vas diagnosed as cerebral 
hemiplegia. In the latter, however, the knee and elbow 
phenomena are not abolished, as was the case in this in. 
stance. This indicated a spinal origin, and the lubseqaent 
history of thfl case, great mnsoolar wasting, Ace., proved it to 
be one of infantile paralysis. Whilst in another case, trfaich 
was diagnosed as infantile paralysis in the apper and lower limbs 
of one side, I found increased tendo-muscular phenomena, and 
the case proved tobeoneof cerebral hemiplegia with descending 
sclerosis. 



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Reflex Action in DiaffnotU. 71 

la adult spinal paralysia, that i§, acute anterior cornnal 
(or polio-) myelitis, the tendo-muscnlar phenomena are speedily 
abolished. Their absence is greatly ia favour of its being an 
organic disease, whilst their presence would be conclusiTe 
againat the abore disease, at all events. Of conrse in this 
complaint there would be complete paralysis and no aniesthesia 
of the affected parts, and the muscles would rapidly waste. 
With the exception of the rapid and extreme wasting, hysteria 
may pnt on the form of anterior cornnal myelitis, but in 
hystfria the tendo-muscular phenomena in the limbs affected 
would probably be present. Dr. Bnzsard states that he has 
never yet seen them absent in hysteria. 

In general spinal paralysis the phenomena would be absent 
or not according as the portion of cord corresponding to the 
origin of the motor nerve to the muscle was or was not affected. 

Similarly in progressive muscular atrophy. In this disease 
the tendo-mnscular phenomenon is sometimes exaggerated, 
but there is in snch cases concomitant disease in the lateral 
column (BuEsardJ. 

In diphtheritic paralysis the phenomena disappear, and 
retOTQ with reinming voluutary power. Seeing that there is 
in these cases also anfesthesia it is probable that the diphthe- 
ritic lesion producing the paralysis is in the spinal cord. 

In psendo-bypertrophic paralysis the muscular iibres become 
destroyed, nndei^oing fatty degeneration, whilst there is a 
coniiderable development of connective fibrous tissue. Hence 
there can be nr contraction of any kind. In his work on this 
disease Dr. Oowers states that it is diminished at first, and 
finally disappears. Probably in other diseases of muscle, such 
as inflammation, it will prove to be absent. 

In a case of general paralysis of the insane, recorded by West- 
phal in the ' Berl. Klin. Woch.,' there was sclerosis of the 
posterior root zones as in tabes, but no ataxia. 

My colleague, Dr. Savage, tells me that it is the rule for the 
tendo-muscular phenomenon to be exaggerated in general 
paralysis nnloss there be ataxic symptoms in addition, I have 
examined twelve cases, some at the National Hospital, but most, 
with Dr. Savage's permission, at Bethlem Hospital. Of these it 
was exi^gerated in five; normal or only slightly marked in 
three ; absent in three, of whom one bad slight ataxic symptoms, 

, Gooj^lf 



72 Reflex Action in IHagnotit. 

not being able to stand with eyes closed and feet togetheTj nor 
to turn suddenly vhen walking, &c. ; the other two had no 
ataxic symptoms. The remaining case was that of a girl only 
twenty-one years of age, who had been an actress, in whom the 
symptoms of general paralysis of the insane were well marked, 
hut she had no ataxia; the knee phenomenon was veil marked 
in the left leg, hut completely absent in the right. 

Hence it appears that in general paralysis of the insane the 
tendo-moscolar phenomena may be normal or even exaggerated, 
or may be absent ; and when absent there may or may not be 
ataxic symptoms. Id no case where the knee phenomenon was 
present were there ataxic symptoms. 

Lesions of sensory nerves or motor nerves alone are not often 
met with because the spinal nerves are all mixed nerves 
beyond the junction of the posterior (sensory) and anterior 
(motor) roots, and the roots are seldom implicated. Bnt when 
lesions do occur in either root or in a mixed nerve the pheno- 
mena are absent. Thus in meningitis which involves the roots, 
and in section of the anterior croral nerve (Erb) they are 
absent. 

Lastly, that their absence may follow loss of tone in the muscle 
from any cause, is a generalised statement, which I beheve will 
be found to be fully borne oat, as our experience grows, which is 
supported by the facts already adduced, and which receives 
additional support from Westphal's observation, that the 
phenomenon is absent for s short time Just after an epileptic 
fit. 

2. The tend 0- muscular phenomena may be exaggerated. 

Before enumerating in what diseases they are exaggerated, a 
condition may be described closely allied to these phenomena, 
and generally found occurring where they are exaggerated. 
This is the so called clonus. 

The beat idea of clonus may be obtained from what might be 
called the natural ankle clonus. It must be in the experience 
of most, that when whilst seated the heel is raised, the toes 
still resting on the ground, the teg can be set into a rapid up 
and down movement by a series of alternate contractions and 
relaxations of the gastrocnemius and soleus, which though 
voluntary at first, go on quite involuntarily after the initial 
movement. 

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Reflex Action in IHagnotii. 73 

Id certun dueases, if the lower end of tbe thigh be supported 
by one hand and the foot of the daagling limb be grasped by 
the other near tbe toes and raised so as to bring the leg half 
way or more towards complete extension and then suddenly 
flexed on to the leg, so as to put the gastrocnemiug and soleus 
suddenly on tbe stretch, they are thrown into a similar series 
of alternate contractions and relaxations, so long as the toea 
are kept pressed towards the leg in front. This is called the 
"ankle clouns." It cannot be obtained in health in this 
way. A variety of it is obtained by twisting the foot iawards 
so as to stretch the peronei, which then are thrown into 
clonns. 

A similar series of alternate contractions and relaxations can 
be obtained in the qaadriceps extensor, by placing the lower 
extremity in perfect extension, the muscle being quite relaxed, 
so that the patella moves freely over the joint, and then 
exerting sudden tension upon the moscle and keeping it ap, 
either by a pnil npon the patella, or better (Oowers), by placing 
tbe finger above the patella and percussing it downwards and 
slightly backwards, keeping it well pressed against the upper 
edge of the patella. This is called the knee clonns. 

There is a slow form of knee clonus obtained but very rarely, 
by percussing the ligamentum patellfe. The foot swings for- 
vrards and backwards like a pendulum (Oowers). 

A umilar clonus can be obtained in the great toe by suddenly 
extending it so as to stretch the plantar muscles. And one at 
the wrist, by suddenly extending the fingers and hand, so as to 
stretch the flexors. No clonus can be obtained at the elbow- 
joint. Hence the various kinds of clonus may be enume- 
rated as 

{quick, 
slow. 

. , , , fdirect — gastrocaemius and soleus. 

Ankle clonus -^ i , . 

tlateral — peronei. 

Toe clonns. 

Wrist clonus. 

In all these varieties, except the slow knee clonus, the 
movements are remarkably rapid and uniform. There are from 
6 to 8 contractions per second, or 860 to 480 per minute, a 
rapidity almost too great to be counted, Dr. Gowcrs has. 



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74 Refiex Action in Diagnoiis. 

however, made tracingB on a revolving drum, the writing point 
being attached to the foot. He was then able to calculate the 
namber per second, and to point ont that the tracings were 
very regular, and that there is no complete relaxation between 
the contractions, a certain amount of ' residual contraction 
remaining between each," which residual contraction is greater 
after several contractions. He says the clonic contractions are 
the result not of a redes but of a direct stimulation of the 
muscle by the sudden tension or vibration, but that the muscle 
is in a state of irritability to such tension, and that this irrita- 
bility is brought about by a reflex action through the cord, the 
afferent impulse arising in the muscular fibres by the sudden 
tension put npon them. 

"Whether this be true or not, the phenomenon cannot be 
produced unless the reflex loop between muscle and cord 
be present. The sudden flexion of the foot sets up the first 
contraction, and as the muscle is relaxing the flexion is kept 
up, and so starts another contraction, and so on, producing the 
clonus, But clonus cannot be obtained by a sudden flexion of 
the foot in a state of health, so that its presence indicates 
disease. 

Another phenomenon is always obtainable where there is 
ankle clonus, and sometimes it comes on before the clonus in 
disease. This is the front tap contraction described by Gowers. 
It consists in flexing passively the foot on the leg so as to put 
the tendo Achillis and its muscles on the stretch, and percussing 
the muscles on the front of the leg (tibialis antlcus, fee.). The 
vibration passes through to the gastrocnemius and solens behind 
and causes them to contract. It is a single contraction, but it 
often sets up the clonus if the foot be kept flexed. 

Increased tendo-muscular phenomena, front tap contraction 
and clonus, all occur in the same diseases. And whenever clonus 
can be obtained in a muscle the tendo-mnscular phenomenon of 
that muscle will be exaggerated. For example, whenever there 
is ankle clonus a blow on the tendo Achillis will cause a much 
greater oontraetion of the gastrocnemius and soleus than is 
normal. But clonus cannot always be obtained where there is 
distinct and even great exaggeration of the tendo-muscular 
phenomena. 

The diseases in which these exaggerations occur are ; 

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Reflex Action in Diar/notia. 75 

a. Lateral scleroais. 

1. Primary or idiopathic. 

2. Second arf to 

Mjrelitis of cord. 
Tumoura of brain. 
HKmorrliage in brain. 
Compressioa of cord. 
Pott's disease. 
Contusion of cord. 
Disaemiuated sclerosis. 

b. Chronic rhentnatic affections. They are only rarely fonnd 
in these affections, and in those cases where they can be ob- 
tuned, there are other evidences of secondary changes in the 
spinal cord (Qowers). 

e. Epilepsy, after the fit (Jackson). . 

d. FaralysiB agitans (a few cases). 

It thus appears that in all those cases whose pathology is known 
there is sclerosis in the lateral columns of the spinal cord {vide 
diagram, p. 65) ; and in the post-epileptic cases, Dr. Hughlings 
JacksoD suggests that there is an exhaustion of the lateral 
columas. 

The question at once arises, ho* does a lesion in this portion 
of the cord cause exaggerated tendo-muscular phenomena. 
^Three theories have been offered. 

1. Irritation. — It is said that the chronic inflammation 
(which constitutes sclerosis) of the lateral columns irritates and 
keeps up irritation in the anterior motor cells, and so increases 
the reflex irritability of the cord. The latter part assumes the 
troth of the reflex theory. If the atonic theory be the correct 
one, we might say that the irritation causes increased tone in 
the muscles, and so they more readily respond to local stimula- 
tion. That it does produce increased tone is shown by the fact 
that the masdes gradually contract more and more until rigidity 
■npervenes. 

2. Bemoval oif cerebral infitunee. — Normally the brain is said 
to inhibit the reflex action of the spinal cord. Hence if its 
inflaence be removed, the reSex irritability of the cord would be 
greater. Under the same conditions the tone of the muscles 
would be increased. 

8. Vhantagomaed cerebellar action, — Dr. Hnghlingt Jackson, 



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76 Reflex Action in DtagnoBia. 

wfao proposes this theory, says that Bormally ihe cerebrum aod 
cerebellum each has its owq Bpecial iafluence on the cord, and 
that these iDfloeoces antagonise each other : that in lateral 
sclerosis the cerebral influence is cut off, and thus the cerebellar 
influence, which is to cause contraction of musclcB, is unopposed; 
and hence the phenomenon of increased irritability which 
finally goes on to rigidity. 

The difficulty with regard to the last two theories is that 
neither the rigidity nor even the exaggerated tendo-mascular 
phenomenon comes on immediately when the cerebral influence 
is removed. But it must be remembered that a sudden brain 
lesion makes a deep impression on the spinal cord. I hare 
seen a case of recent apoplexy with right hemiplegia in which 
there was complete absence both of superficial reflexes, and of 
the tendo- muscular phenomena, which gradually returned. 

The important point to remember, however, is the fact that 
BO far as pathology bag thus gone, iacreaoe of the tendo- 
muscular phenomena, and a fortiori, clonus, which is a farther 
development of the same, indicate lateral sclerosis of the 
spinal cord, i,e. sclerosis in the crossed pyramidal tracts (ot(f« 
Fig. 2] p. 65) ; and the particular muscle afi'ected will localise 
the spot in the cord. Thus, ankle clonus means lateral sclerosis 
in that part of cord which gives off the sacral nerves, whilst 
exaggerated knee phenomenon indicates sclerosis where the 
third and fourth lumbar nerves come off (anterior crural). 
Hence a transverse myelitis at the origin of the third and fourth 
lumbar nerves would cause abolition of the knee phenomenon ; 
and if scleroeis descended from that myelitis, there would be 
increased ankle phenomena, and perhaps ankle clonus. 

Theoretically anything that will iucreaae the irritability of 
the muscle might cause increased tendo-muscular phenomena, 
or even clonus, and bo irritation of sensory or motor nerves, or 
an irritable condition of the muscles themselves from disease, 
may possibly be discovered as causes of these phenomena as 
our knowledge advances. 

The commonest cause met with is descending sclerosis in 
ordinary cerebral hemiplegia. Westphal has seen a case in 
which ankle clonus and increased knee phenomenon came on an 
hour after an attack of apoplexy ; but this must be exceedingly 
rare. A« a rule it takes more than a week, during which inflsm- 



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Reflex Action in Diagnotis. 77 

BMtoTf changea are going on down the motor tract from the 
htemorrhage in the brain. 

Hence it is important in cases of hemiplegia to test these 
phenomena, for if they begin to be exaggerated, rigiditj' will 
probabl; Bnperrene. Charcot says it will certainly come on, 
bnt there are exceptions. The following ia a case of spinal 
cturature, probably with myelitis and descending sclerosis in 
conaeqaeDce : 

A. E. D — , girl^ St. 12, attending my out-patients' at the 
Nfttiooal Hospital since beginning of present year. She has 
had spinal carratnre in the dorsal region for five or six years, 
with gradually increasing loss of power in the lower limbs. 
She cannot valk -withont assistance, and her feet are dragged 
along the ground. 

Greatly increased tendo-mnscnlar phenomena in both lower 
limbs, ankles and knees, and also ankle clonus and knee clonns. 
Elbow phenomena present but not exaggerated. Wriat 
phenomena absent. No anKsthesia. 

The following is a case, also attending at the National Hos- 
pital, in which I believe there is lateral sclerosis, probably 
secondary to some cerebral mischief. 

Alice T— ^, ct, 18, bad conTnlsions soon after birth, and 
about the same time her head became rery large. Has always 
been very slow intellectnally, and her memory ia bad. No 
weakness and no loss of sensibility. Head now measures 
twenty-four inches. She has rather the appearance of hydro- 
cephaias, and there is slight external strabismna of the right 
eye; bnt when she is asked to follow some object the eye 
adjosts itself, and both eyes then follow the object quite 
normally. No diplopia. All the tendo -muscular phenomena 
well marked, including that of the wrist. Knee clonus on 
both sides. Snperfidal reflexes fairly well marked on both 
sides. 

The following is a case of epilepsy, the patient working in 
lead as a painter. The tendo-muscnlar phenomena are much 
exaggerated, and it is a question whether they have any con- 
nection with the fits or the lead, or are quite independent. 

James H — , «t. 84, subject to fits for eighteen years. Has 
always worked in lead and has had colic, and generally suffers 
from constipation. The fits last a few minntes, and he struggles 

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78 Reflex Action in Diagnotit. 

a great deal. His warning is a glimmer before tbe eyes, or a 
cutting pain in the stomach. 

Knee, ankle, elbow, and wrist phenomena are greatly 
exaggerated on both sides. No clonus. 

The following is an interesting case with wrist clonns, which 
is rare: 

Louisa S — , set. 45, came to my out-patients' at the National 
Hospital on the 8tfa November, 1880. She had rheumatic fever 
fourteen years ago. Eighteen months ago had an attack of 
light hemiplegia, with partial aphasia, the latter lasting sereral 
weeks. 

After a time she recovered use in the right leg, but the hand 
has remained nearly useless. She can raise the right arm a 
little, but cannot flex the forearm on the arm, nor flex the 
Angers. There is a well marked thrill and a load presystolio 
bruit. 

All the tendo-mnscolar phenomeoa are greatly exa^erated 
on the right side, and better marked than normal on the left. 
Aukle, knee, and wrist clonus on the right side. The wrist 
clonus is obtained by taking hold of the patient's wrist with 
the left hand, and placing the tips of the fingers of the right 
hand under those of the patient's band and suddenly rusing 
them so as to extend the wrist, and pnt the flexors of the fore- 
arm on the stretch j they begin to contract and relax rapidly 
(six per second], but soon stop. The wrist clonus ia always 
obtainable when she first comes into the room ; but after 
trying it seTeral times, it cannot be further obtained, for 
what reason is not clear. There is no clonus obtainable on the 
left side. The diagnosis here is cerebral embolism from mitral 
stenosis, with subsequent descending lateral sderoais. 



S. The fecial setuea. 

The reflex actions in connection with the special aeases of 
smell, taste, and hearing are neither nomeroaa nor important as 
aids in diagnosis. Exaggerated reflex symptoms may occur in 
connection with them. For instance, odours may cause vomit' 
ing, an attach of asthma, or fiiinting ; similarly, sounds some- 
times cause syncope. Bat the most important nerre in reapect 



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Refiex Aelion in Diagnoiit. 79 

to reflex action in the diagnosis of disease is the optic. This 
results from the fact that the iris is visible, so that its move- 
ments can be seen through the transparent cornea. 

The two sets of fibres, the radiating and the circular, of 
which the iris is composed, are of the involuntary kind, and are 
constantly in a state of slight tonic action, which is kept up by 
two separate nerves. 

The tonic artion of the circular fibres is kept up by a reflex 
process through the optic and the third nerves, and not by an 
automatic influence of the ganglionic centre of the latter nerve 
in the aqueduct of Sylvius. This is proved by the fact that 
when the optic nerve is cut the pupil dilates, and no further 
dilatation is produced by cutting the third nerve. 

The tonic action of the radiating fibres is kept up by the 
sympathetic nerve, not by any reflex process so far as is known, 
but by an automatic influence constantly streaming from a 
dilating centre in the aqueduct of Sylvius (just behind the 
origin of the third nerve), down the spinal cord, and out at the 
lower cervical, and one or two upper dorsal nerves, and so into 
the sympathetic. When, therefore, the eyes are shaded or the 
eyelids closed, the tonic influence of the sympathetic is unop- 
posed, and the pupils dilate. It is said that the sympathetic 
which supplies the radiating fibres of the iris does not pass 
through the lenticular ganglion but passes with the first 
division of the fifth nerve, and along its nasal branch, and 
thence through the long ciliary nerves, Moreover, the fifth 
nerve is said to have fibres in its first division, derived from 
the Gasserian ganglion, which are able to dilate the pupil 
independently of the sympathetic, though it is thought by some 
that these fibres of the fifth nerve act really on the blood- 
vessels of the iris and thus influence the pupil indirectly. The 
sympathetic acts directly on the radiating fibres, for it will act 
in a bloodless eye. 

Whenever a sensory nerve is strongly irritated the pupils 
dilate. This occurs after excision ^ the superior cervical 
ganglion in an animal ; from which Vulpian, who performed 
this experiment, argued that other nerves supply the radiating 
fibres of the iris, besides those which pass along the sympa- 
thetic. 
But the dilatation of the pupil following strong stimolation 

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80 Reflex Action in ZKofftioii*. 

of a Gensory oerre may be due to inhibition of the third nerve. 
To Bee if this were so or not, my colleague. Dr. Pye-Smitb, has 
been kind enough to make the foliowiiig experiment : 

A large cat was placed under the intluence of chloral (SO 
grains). Tracheotomy was performed and artificial respiration 
commenced. 

The left superior cervical ganglion was next excised. 

The left pupil became smaller than the right. 

The right sciatic was now stimulated with progressively 
stronger currents of the Dubois-Reymond induction coil. 
With the secondary coil at 20, no effect was produced ; at 15, 
still no effect ; lastly, at 10, the strongest current employed, 
the right pupil dilated a little, the left remaining as before. 
The pupils responded freely to a considerable stimulus, but 
after being contracted by artificial light they both dilated on 
stimulating the right sciatic with the secondary coil at 10. 

The skull was now opened and the left third nerve divided. 
A bright light produced contraction in the right pupil, but bad 
no efiect on the left. 

The right sciatic nerve was again stimulated with the secon- 
dary coil at 12, 10, and 8 respectively, producing dilatation in 
the right pupil and no effect in the left in each case. 

When allowed to remain undisturbed, under diffused light, 
the left pupil (third and sympathetic both divided) remained 
widely dilated, whilst the right pupil (no nerve divided) re- 
mained very contracted. Next, the distal end of the divided 
third nerve was stimulated, producing retraction and internal 
BtrabiBmuB of the left eye, but no contraction of the pupil. 
(The heart was beating very feebly and the abdomen had 
already become cold.) 

The above experiment shows that the fifth nerve has no 
fibres in it which cause dilatation of the pupil on strongly 
stimulating a sensory nerve, but that this result is brought 
about through the third nerve, probably by inhibiting the 
tonic influence kept up reflezly by this nerve upon the circular 
fibres of the iris. 

The third nerve supplies both the circular fibres of the iris 
and the ciliary muscle, and when the latter acts during accom- 
modation the former acta by association, and thus the pupil 
contracts. 

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RefUx Action in IHoffnosi*. 81 

Tlie size of the pupil can be altered also by drugs, duboiaia, 
stropia, pbyBOStigmitij &c. 

Practically if tlie papil responds to either light or accommo- 
datioD it will also to drugs. But it may respond to light and 
not to accommodation or to accommodation and^ot to light, or 
to neither accommodation nor light ; in the last case drags may 
or may not produce an effect. Again, each eye must be examined 
separately and in combination with its fellow. If the left eye, 
for example, be closed, and the right eye does not now respond 
to light, but contracts on opening the left eye, it indtcateB 
lesion in the afferent sensory path of the right eye, which will 
be found to be blind. If one eye be blind from a lesion in the 
optic nerve the pupils of both eyes contract readily when light 
falls upon the sound eye. 

Drugs are to be used when light and accommodation fail to 
produce any action. Atropine dilates and eserine contracts 
unless there be some disease in the iris itself, or some adhesion 
from preTious iritis or glaucoma. 

It would greatly facilitate matters if it could be stated that 
under a given degree of illumination the papils would be a 
certain definite size, which could then be taken as a standard. 
Bat though this can not be done, considerable variety being 
met with in different individuals, yet certain generalised state- 
ments may be mad^. Under diffuse daylight with the accom- 
modation relaxed the pupil averages 3^ mm.^ 

Such a pupil when the patient accommodates to a near object, 
say at a distance of two feet, contracts to S mm. In other 
words, in passing from the relaxed condition to one of accom- 
modation the pupil contracts half a millimetre (= -^ih inch). 
Much variation will be met with not only as to the amount ^ 
the diminution in size bat also in the rapidity with which it 
takes place. It has been my impression, whilst examining a 
la^e number of cases, that it is more in quantity and greater 
in rapidity in young people than in old, in women than in 
men, in the weak than the strong. 

The pupil is larger in dark than in light^coloured eyes. 

> All meunvemaitt ue taken bj raeua of NflttlMhip'i Poptlometer, which 
ooiwitt* of a Mriei of round black ipoU on a osid, each ipot nDmbered. Guh 
iranber sboin Um diametsr in uillimiUM, and the mcaaorement U taken bj 
comparing tlM epoti with the papll, the card being held flat with ths iiij, and 
doM to the ontei canthni. 

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82 Reflex Action in Diagnosis, 

If tbe pupils be closely watched whilst the patient is gaziag 
on a fixed distant object, they will be observed to oscillate irre- 
gularly ; and if by ineaDS of a pencil the contractions be repre- 
sented on paper by an upstroke, and the dilatations by a 
downstroke, a tracing will be obtained ahowing a certain 
number of movements in a given time, say thirty seconds. If 
now the patient accommodates by looking at a near object, the 
pupils still oscillate irregularly, and if a tracing be taken, as 
before for thirty seconds, it will be found that the movements 
are not so frequent, nor are they so great. I have taken a 
great many tracings in this way, and have found that the oscil- 
lations in thirty seconds, when the accommodation is relaxed, 
are about twice as many as when the eye is accommodating for 
near vision. 

Tbe average number of oscillations during relaxation is about 
ten in thirty seconds, and about half that number during 
accommodation in the same number of seconds. 

This phenomenon is quite absent in those cases of locomotor 
ataxy in which there is the A^^li-Bobertson pupil (reaction 
to accommodation, not to light). In all probability, therefore, 
they are due to the varying degrees of light. They are not 
synchronous with tbe pulse nor with respiration, although 
slight movements have been said to occur with these (Foster's 
' Physiology,' p. 467). 

Dilated pupils. — The emotions, as is well known, will cause 
the pupils to dilate. In all probability they act through the 
sympathetic, for not only do we get accompanying vaso-motor 
phenomena (pallor of face] in many instances, but also if the 
corpora quadrigemina of an animal be stimulated after removal 
of the cerebrum, cries as of pain are produced, and tbe pupil 
dilates. It does not dilate, however, if the sympathetic nerve 
in the neck be previously cut. 

Exhaustion causes dilatation of the pupils. They are larger 
in weak than in strong people. They are dilated during, and 
for some time after, a strong convulsive attack, as in epilepsy. 

At tbe National Hospital for the Paralysed and Epileptic I 
have several times correctly inferred from the dilated pupils 
that a patient has just had a fit before coming into the room. 
They do not contract readily to light, and during the fit they 
are immovable to light. Dr. Gowers tells me that they 

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Refitx Action in Dia^notis. 88 

continue anxeflponsiTe to light for a short time aflet a fit. 
They aie dilated during djspncea, partly, perhapa, through the 
muscular exertion which may end in a convulsion, and partly 
to the mental emotion. In other words, it is probably through 
the sympathetic. They reset to light and accommodation in 
this condition. 

The pupils generally become widely dilated at the point of 
death. They are nearly always larger than normal for some 
time aft«r death, but in a few hours they hare contracted so as 
to be of medium size. In some cases they remain dilatedj 
especially if the eyelids are kept closed. 

Mention has already been made of the fact that strong irrita- 
tion of any sensory nerve will cause dilatation of the pupil, 
and reasons were adduced for believing that the result is pro* 
daced partially, at least, by inhibition of the third nerve. 
Probably the sympathetic also acts directly on the radiating 
fibres, for there is often pallor of the face (vaso-motor pheno* 
menon), produced by great suffering. 

Any one who will take the trouble to watch the pupils 
whilst a tooth is being extracted, will notice the wide dilatation 
produced, especially if the operation be difficult and prolonged. 
I have watched it not only in these cases, but also in other 
painful operations, where the patients have refused ansesthetics, 
as in examinations of wounds and bruised limbs, the reduction 
of dislocations, &c. ; and though a man may, by the powerful 
inhibiting influence of his will, restrain cries, muscular 
twitchings of face, and even the setting of his teeth, he cannot 
prevent his pupils dilating. 

It is useful to remember this in cases of malingering. For 
patients will stand a great amount of pain, such as that pro- 
dnced by the electric battery, in order to keep up some feigned 
disease — for example, in railway injuries. Dilatation of the 
pupil, pallor of the face, or other vaso-motor disturbance pro- 
duced by strong stimulation of a sensory nerve, tends strongly 
to prove that the patient can feel. It does not, however, 
absolutely prove it, because the lesion might be in the highest 
cerebral centres on the cortex of the brain, though there would 
in most cases be evidence of this. 

Dn^ will cause the pupils to dilate. Of these beUadonna 
■nd it* active principle atropia ate the most important. The 

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84 Sefiex Action m ZHoffnosU. 

ciliary muscle is nt the same time paralysed, so that there ia 
defect of vision from inability to accommodate. If there be 
hypermetropia araanrosis is much more readily induced, and a 
much smaller quantity of the drug aoffices to induce it. 

Other drugs, such as stramonium and hyoscyamue, also 
cause dilatation of the pupil, either locally applied oi 
internally taken. They ore not so extensively used as bella- 
donna. Duboisia is now largely used; it is more powerful 
than atropia. It is thoiight that these mydriatics both paralyse 
the third nerve and stimulate the sympathetic. When fully 
dilated there is no reaction to light. In all cases where 
the pupils are dilated the possible use of some drug, such aa 
belladonna, should be inquired into. 

It is scarcely necessary to mention that adhesions of the iris 
are indicated when atropia produces no result. 

AneestheticB, such as chloroform, cause first contraction of 
the pupils, but if pushed too far the pupils dilate ; hence the 
condition of the pupils is a valuable aid to the chloroformist. 

From what has been already stated it is clear that disease 
affecting any part of the afferent sensory tract will cause dila- 
tation of the pupils. Hence we find the pupils dilated behind 
opacities in die cornea, in front of opacities in the lens (e.^. 
cataract), oi opacities in the vitreous humour, destructive 
lesions of retina, optic atrophy, optic neuritis when there is 
much affection of vision (although it is remarkable to what 
an extent optic neuritis may exist without causing dilata- 
tion of the pupils), and disease in the optic nerves, optic tracts, 
and corpora quadrigemina. The dilatation is due to the 
unopposed tonic action of the sympathetic. In all the cases 
vision is impaired or entirely lost. 

They are dilated in effusions of blood within the cranium^ 
especially when large, and more especially when in the ven- 
tricles. Sr, Wilkflj in his work on ' Diseases of the Nervous 
System,' mentions the importance of remembering this, inas- 
much as the patient, who is of course always unconsciooa with 
such a lesion, may be thought by the friends to be asleep ; but 
the pupils are contracted in sleep, so that by raising the eyelids 
one can immediately detect the gravity of the case. 

Id ophthalmoplegia interna (paralysis of the ciliary muscle 
and the dtcnlar fibres of the iris) the pupils ara dilated 

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Refiex Action in Diagnom. 86 

and immovable to light, and the power of accommoda- 
tion is lost. No lesion has hitherto been demonsttated poet 
mortem in this disease, and it is curious that there are no less 
than three different theories as to the actual seat of disease. 
Kr. HutchioBon, who first described the affection, considered 
that the lesion would probably be found in the lenticular gan- 
glion ; he still holds that view. Mr. Hulke has brought for- 
ward quite receutlf, at the Ophthalmological Society, his opi- 
nion that it is in the peripheral endings of the ciliary nerves } 
whilst Dr. Gowers,in the debate which followed, expressed his 
cimTiction that it was at the central origin of the third nerve, 
somewhere near the aqueduct of Sylvias and corpora quadri- 
gemina ; and he brought forward several iacts tending to support 
his view, 

Cydoplegia or paralysis of the ciliary muscle is rare. 
Th«re is no mydriasis, and the pupils react to light. It ocxmrs 
sometimes after diseases producing great exhaustion, such as 
diphtheria. The cause is probably central (Hutchinson). 

The external ocular muscles may be paralysed without any 
affection of the iris and ciliary muscle, and this condition is 
called ophthalmoplegia externa (Hatchinson), 

These various affections, in which different parts of the third 
n^ve are picked out as it were and the rest left intact, are pro- 
bably due to central causes ; and Dr. Allen Sturge suggests in 
his papeTj read at the Ophthalmological Society, May, 1881, 
that there may not only be different nuclei of origin for different 
portions of the third nerve, bat also higher co-ordinated centres 
which, when afiected, would cause paraljrsis of the muscles 
acting together, such as the two superior recti. 

Paralysis of the levator palpebrfe and the external ocular 
muscles sapplied by the third, together with a motionless and 
dilated pupO, and inability to accommodate, indicate a lesion in 
the trunks of the third nerve. 

The pupils are dilated in protrusion of the eyeball. In a 
case of exophthalmic goitre, however, I found the pupils of 
normal size; they reacted to light and accommodation, and 
oscillated normally ; they dilated on passing a strong fitradic 
current through the neck. 

The pupils are dilated vhen Ut« aqueous humour is in 
excess. 

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86 R^lex Action in Diajniom. 

Tobacco or ita active principle causes dilatation of the pupil. 
They act to light and accommodation, but there ia probably 
some dimness of vision. The " central region of the visual 
field is the part first affected, and remains throughout the seat 
of greatest relative defect; and, farther, the periphery of the 
visual field remains of fall size " (Nettlesbip, * St. Thos. Hosp. 
Rep./ vol. is). 

The pupils are not onfireqaently dilated in typhoid fever, 
whilst they are contracted in typhus. Dr. Muichison says, 
however, that they may be contracted in typhoid, especiijly 
where there is great stupor and complete unconscionsness. 
There is an»mia as a rule with dilatation, hypertemia with 
contractioQ. Indeed, in most cases of ansmia, as in aortic 
regurgitation and chlorosis, the pupils are large, and in hyper- 
nmiBj as in bronchitis or mitral regurgitation, they are small. 

Contracted pupilt. — Irritating lesions of the third nerves or 
paralytic lesions of the cervical sympathetios cause contracted 
pnpib. Clinically such lesions are mostly met with on one 
side only ; the pupil on the side affeoted is tmallei than the 
other. 

When in locomotor ataxy the pupils are contracted and 
do not react to light, they do not react to a strong stimulus 
passed through a sensory nerve (Erb) ; nor do they exhibit the 
variations in size met with in the normal condition. They 
respond to accommodation. Erb tries to explain these phe- 
nomena by supposing that the influence of the sympathetic 
is cut off by disease in the dilating centre in the aqueduct 
of Sylvius; or it may be in some part of the tract leading 
from this, along the spinal cord, as far as the second dorsal 
nerve. The absence of reaction to light is explained by 
another hypothetical lesion between the corpora quadri- 
gemina and the origin of the third nerve in the aqueduct 
of Sylvius ; as this cuts the reflex loop to the circular fibres of 
the iris, and there is no tonic action exerted by the third nerves 
except reflezly, the pupils ought to be of medium sise when 
the accommodation is relaxed ; the ctmtracted state is not yet 
accounted for. 

In some cases of locomotor ataxy the pupils dilate on strongly 
foradiziDg a sensory nerve. Dr. Gowers tells me that in such 
cases the pupils also react to light. 

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Reflex Action in Diagnosit. 87 

Another pointj interesting on account of its relation to the 
sympathetic lesion^ is that in nearly all cases of ataxy the pulse 
is quick and dicrotic. In most cases it will be found to be 
orer 100 per minute. 

It may be mentioned here that the pupils are contracted and 
the pulse quickened in poisoning by chloral hydrate, carbolic 
acid, chloroform (early stages), or opium. 

During sleep the pupils ore contracted and the pulse is 
slower than Trhen awake. 

In some cases of apoplexy, such as bleeding into the pons 
Varolii, the pupils ore contracted and the pulse usually 
slow. 

The pupils are smaller in old age, quite apart from any 
disease. They react both to light and accommodation, and are 
thus easily distinguished from the contracted pupils of tabes 
dorsalis. 

The pupils are small in typhus ferer (ritf« ante). 

It has often been stated that the papils are contracted in 
unemic coma. Dr. Wilks (op. cit.) says they are not affected, 
and the comparatiTely few cases I have seen confirm the latter 



Unequal pupiU. — Lesions of the cervical sympathetic of one 
side produce alteration in the pupU of the same side, generally 
causing contraction. This is met with in aneurism and tumours 
in the neck and thorax. The pupils react to light and accom- 
modation. In some coses this inequality of the pupils aids the 
diagnosis of intrathoracic growth from Talviilar cardiac disease. 
Disease in the cilio-spinal region produces the same effect. 
The inequality is best seen in a dull light. 

Lesions of the third nerye on one side produces inequality 
of the pupils. This condition is met with in tumours at the 
base of the brain and injuries to the skull. There is no 
reaction to light, nor to accommodation, on the affected aide. 

Both the Uiird nerves may be affected in different degree, 
the pupils unequal and contracted or one dilated, as some- 
times happens in tubercular meningitis. They may respond 
feebly to light or be motionless; the condition is one of some 
importance in diagnosing between this disease and typhoid 
fever. 

Immobility of the pupils to light and to accommoda- 

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88 Refiex Action tn JHagnona. 

tioD, with so p&ralyeis of the muscles of the eyeball, may be 
due to adhesion of the iiis from previoits inflammation ; the 
pupUa on close examination are usually irregular, and atropine 
fails to produce dilatation. 

A blow on the eye sometimes causes dilatation of the pupil, 
probably from paralysis of the circular fibres of the iris ; the 
dilatation may last for months. At first there is no contxaction 
to light, not to accommodation ; afterwards the pupil responds 
to both even before the normal size is regained. 

Hsemorrhagea into the brain or on the surface cause inequa- 
lity of the pupils vhen the third nerve is affected. In acute 
disease of the brain there is inequality of the pupils, hut no 
definite relation between the two has been established (Wilks). 
In general paralysis of the insane the pupils vary. MoBt 
frequently they are both contracted either equally or varying 
in degree, or one pupil may be dilated, and the other normal 
in sise or contracted. In cases where there are tabetic symptoms 
in addition, the pupils do not react to light, but contract to 
accommodation. 

Through the kindness of my colleague. Dr. Savage, I have 
been enabled to examine several cases of general paralysis at 
Bethlem Hospital. I purposely took those cases with no 
symptoms of ataxia. In all the cases of undoubted general 
paralysis of the insane, the pupils were contracted to S} 
millimetres ; in most of them equally so, in a few they were 
unequal. They contracted still further on accommodation, but 
not at all to ligbt. On passing a faradaic current through a 
sensory nerve (one electrode on the spine about the seventh 
cervical, and the other on the neck behind the middle of the 
sterno-mastoid), no dilatation was obtainable (the current 
was not very strong). The oscillations of the pupil which I 
have described were quite absent. 

It would thus appear that the pupils in this disease are 
exactly the same as in locomotor ataxy. There is one point, 
however, that, if confirmed in a larger number of cases, may be 
useful in diagnosis. Mention has already been made of the 
fact that in locomotor ataxia the pulse is quick, generally over 
100 per minute. On the other band, in general paralysis of 
the msane, with the same condition of pupils, the pulse is as a 
rule not Above normal, varying firom 70 to 88. All the cosei 

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S^lex Action in Diagnoaii, 89 

examined were males, whose ages varied from thirty-eight to 
sixty. 

lo two cases the pcpils were large. In one case, that of a 
mao, thirty-three years of age, the left pupil wa8=4i milli- 
metres, the right=S millimetres; both reacted to accommo- 
dation, hat neither of them to light nor faradaiam. The patient 
got into a passion whilst under examination, and both pupils 
dilated. Xn the other case, a man, forty years of age, the left 
pupil wassSi millimetres, the right one=4i 'millimetres; 
both reacted during accommodation, but neither of them to 
light nor to faradaism. The pulse in this case was &3 per 
minate. 

Dr. Wilks (op. cit.) mentions the case of a man who insured 
his life and died about two years afterwards from general 
paralysis of the insane. It was found on inquiry that when 
the assurance was effected, the pupils were unequal, and he 
was suffering from general nervous debility attributed to over- 
stody. This illustrates the importance of examining the pupils 
in aU cases. 

Mydriatics and myositics used on one side cause inequality. 
They may be used intentionally to deceive. There is usually 
defect of vision, and in some cases diplopia. There is no re- 
action to light, but in the contraction by eserine there is 
forther contraction to accommodation. The inequality passes 
off in a day or two If all drugs be discontinued. 

It has been said that in people subject to epilepsy the 
pupil of one side is larger than the other, the former being on 
the side which is most convulsed during the fits. Out of a 
lai^e number of cases that I have examined on this point, in 
most the pupils were equal, and in the rest the larger pupil 
was as often on the side least convulsed as on the other. The 
pupils of epileptics have seemed to me rather larger than those 
of other people. 



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A SECOND CASE 



FRAOTTTBE OF THE 8KFLL, 



roiLOwiD BY 



A COLLECTION OF CEEEBE0-3PINAL FLUID 
BENEATH THE SCALP. 



Bt b. olbmbnt litoas, b.s. 



In the 'Guy's HoBpital Bepoiti' for 1876 I have related 
the particaUra of a case in which, af^r a severe simple fracture 
of the skull, a large collection of cerebro-spinal fluid appeared 
beneath the scalp, just above the left ear, in sufficient quantity 
to press down the pinna to a right angle with the head. 
The report is carried up to four mouths after the injuiy and 
two months after the patient left the hospital convalescent. 
I also refer in the paper to two similar cases which have been 
recorded : one mentioned by Ericbsen as having occurred in a 
hydrocephalic child, and one more fully narrated, but deficient 
in post-mortem details, which was reported by Mr. Haward. 

My report of the case was illustrated by a drawing of the 
tmnoori and by a diagram of the fracture so far as it could be 
ucertaioed during life. 

The patient was kept under observation, and one year and 
lune months after the injury she was srised with acute 
meningitiB, which ended fatally in five days. Further details 
of this case, with a report of the very interesting post-mortem 
examination and a drawing of the brain, will be found in the 
'Guy's Hospital BeporU' for 1878, 

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93 A Seetmd Gate <tf Fracture of the Skull, 

It will be sufficient to state here that there was com^dete 
evidence that the cerebro-spinal tumoar had commiinicated with 
the lateral Tentride, the descending and posterior comaa of 
whieh had become together dilated into a large cavity adherent 
to the skoll. 

The following case I am able to relate by the courtesy of 
my colleagne, Mr. Howse, under whose care it was admitted a 
few days before he left London for the summer vacation in 
1878. In his absence the patient fell to my charge, and 1 have 
ever since kept the child under observation. 

B. P — , a boy^ aged one year and eleven months, was 
admitted into the Evelina Hospital for Sick Children on July 
24th, 1878. He had previously suffered from measles and 
pertosais, but not from scarlet fever. 

About five o'clock in the afternoon he fell from a window, a 
distance of about ten feet from the ground, and pitched upon 
bis bead. He was picked up in a state of insensibility and 
brought to the hospital. 

On admission he was quite tlnconacious, and remained in 
this condition throughout the night, but on the following 
morning he recovered his senses sufficiently to take notice of 
persons around him. His temperature at night was 99°. 
During the night there were frequent convulsive movements, 
and the child screamed at intervals. He has been sick directly 
after taking milk. He has passed urine twice, but his boweU 
have not acted. Temperature on the morning of the 25th, 
10I'S°, pulse 108, respirations 28. The whole of the forehead 
is much bruised and swollen, more especially on the left side. 
The left upper eyelid is extensively ecchymosed, of a deep claret 
colour, and too much distended to be raised. The right eyelid 
is slightly ecchymosed, and in this there is no subconjunctival 
ecchymosiB. There has been no discharge of blood or fluid 
either from the ears or nostrils, and there is no paralysis. 
The anterior fontanelle is not closed, and the wrista are some- 
what large. An ice-bag was ordered to be placed on the child's 
head, and three drachms of castor oil to be taken at once. 
Evening temperature the same — 101'3°. 

July 26th. The child has not been sick since yesterday, and 
passed a quieter night, but is unconscious this morning. Pulse 
76, not quite r^ujar in rhythm. Bovehl }iave acted onge, 



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A Second Cate o/F^raeture qfthe ShiU. D8 

The right eyelid is more discoloared to day. Morning tempera> 
tore 99°, evening 100°. 

27tl). — 'He has paued a quiet night. Bowels hare not acted 
since yesterday. He has not spoken nor asked for his mother 
since the morning of the 25th. He takes milk well. False 
fi2> more r^nlar. Morning temperatnre 99°, evening 100'4°. 

28th, — Abont the same. Morning temperature 99*4°. In the 
evening it rose to 102*2°. 

29th. — He is qnite coDBcious. Poise 96, r^nlar. Morning 
temperatore 99'6°, evening 99*2° Swelling of forehead and 
eyelids sabsiding. 

30th. — Morning temperatnre 97-4°, evening 99*4°. 

Slst. — Hard ridges, indicating a line of fractore, can be felt 
on the forehead and scalp, extending back to the anterior 
fontanelle. The internal ridge is most elevated, aod the 
external is apparently depressed. Pnlse 96, not quite regular. 
Morning temperature 97'4°, evening 99*3°. 

Angnet 3rd. — The temperature during the last two days has 
been normal. He is progresaiug well, and sat up, for the first 
time to-day, in bed of his own accord. The swelling of the 
forehead and eyelids has been decreasing so that the ridges of 
bone can be more distinctly felt. 

7th. — Has continued to improve gradually, his temperature 
having been dnring the past foor days sometimes slightly below 
and sometimes a little above normal. His morning temperature 
to-day was 97*8°, but in the evening it ran up to 101*2°. 

9tb. — He is generally fretful, but has been gradoally im- 
proving, and is able to talk to his mother. He sleeps well and 
his bowels act regularly. This morning it was noticed that the 
swelling on the forehead had increased in size, and it coatinaed 
to increase daring the day, becoming towards the evening of 
considerable size. The B^istrar drew off with a hypodermic 
syringe about twenty minims of a clear faintly alkaline flnid, 
containing a few small flakes slightly tinged with blood. 
Yesterday the temperature was normal ; to-day it was 98*5° in 
the morning, bat rose at night to 101*3°. 

10th. — ^To-day it has been noticed that the swelling pulsates. 
It is mnch smaller than yesterday, but it varies in size, increasing 
when the child screams. A ridge of bone can now be felt throagh 
tbe tweDiugt conuaeodng about the noiddle of the left supra- 

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94, A Second Case </ firaeture of the Shdl. 

oibital ridge, and aaceadiDg irregularly on the forehead, some- 
what to the right, as far as the scalp ; it then crosses the median 
line and extends ahout half an inch to the right and beyond the 
anterior fontanelle. Another ridge can be felt, ascending at 
first vertically from the left orbit, then inclining slightly to the 
right to join the fontanelle on the left side. A long narrow 
depression can he felt between the ridges, broader above than 
elow. Morning temperature was 99'4°. evening 100'4''. 

11th. — The temperature taken this morning was QG'S", and 
in the evening it was 97'8°. 

14th. — During the last two days the temperature remained 
normal. This morning it was 98*8°, but in the evening it ran 
up to 103'4°, the highest temperature that has occurred since 
the accident. It was attributed to the excitement caused by 
the presence of visitors to-day. 

ISth.^The morning temperature was 98'4°, in the evening 
the temperature waa 99*7°. 

17th. — Yesterday ths temperature was normal. This morn- 
ing it was 97*8°, but in the evening it rose to 100-4°. The 
swelling of the scalp to-day has almost disappeared. The 
general condition of the child remains about the same. 

30th. — The temperature has remained normal since the last 
report. The swelling of the scalp varies daily, but is never so 
great as formerly. 

September I7th. — There has been nothing of importance to 
notice in the child's condition since the last report. The 
temperature has never, during the last month, reached 100°, 
even at night. The swelling varies from time to time, and is 
especially influenced by crying. A large gap is still to be felt 
in the frontal bone, extending from above the left orbit towards 
the fontanelle. The child is perfectly intelligent, and has a 
good appetite. He left the hospital to-day. 

The child continued to attend among my out-patients for 
some months after it left the hospital, but there was nothing of 
importance to note in its condition. The mother received strict 
orders to bring it up immediately if seized withjfits, sickness, or 
fever. 

November 10th, 1879. — The child was brought up to see me^ 
at my request, to-day. It is now a year and three months 
since the occurrence of the accident. The child has not 



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A Second Caae ttf Fraetvre tff the Shdl. 91 

niffei^d firom fits, nor firom any symptoms tbat could be 
attributed to braiii injury. He appears bright, intelligent, and 
in ordinary health. The mother says that the left eyelid swells 
Then he is excited, and tbat it ^res a heavy look to that eye, 
causing it to appear more closed than the other. He occa- 
sionally puts hiB baud to his head, and sometimes, bnt not 
often, complains of headache. There is no longer any swelling 
on the forehead, but a large fissure can still be plainly felt. 
Tlus SBsnre commences above the left orbit, and after ascending 
a short distance curves slightly inwards, just internal to the 
frontal protuberance. It then continues to ascend upwards 
and inwards to the top of the forehead, lying to the left of 
the frontal fissure, which it afterwards appears to join, and so 
to be continued to the position of the anterior fontanelle, now 
closed. The fissure is widest at the upper part of the fore- 
head, where it is full a quarter of an inch in width. It swells 
np slightiy when he holds his breath and pulsation can be felt 
in it. The drawing indicating the direction and extent of the 
fissure was made at this time. 

February 16th, 1881. — I have to-day again had an oppor- 
tunity of examining the child's head. The fissure has not 
closed, and remains almost precisely in the same condition as 
when last reported. The edges of bone are probably united 
by fibrous tissue. He apparently suETers no inconvenience as a ' 
result of the accident, and is able to attend regularly at school. 
His firiends state that at times tbey still notice a bulging over 
the line of fissure. It is now two years and seven months since 
the accident, but, after the experience of my last case, I cannot 
say that the report is complete. So severe an injury must be 
regarded as a permanent source of danger that may at anytime 
determine an attack of acute meningitis. 

Remarkt. — ^The foregoing report adds a fourth case to those 
already recorded, in which, after a severe simple fracture of the 
vault of the skull, a large tumour of cerebro-spinal fluid ap- 
peared beneath the scalp ; and I think there is now sufficient 
evidence to show that these cases belong to a very rare but dis- 
tinct class of head injuries. 

I would again point out, as I did when commenting upon my 
other case, that the patients who have suffered in this way have 

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d6 A Second Cote of Praeture of the ShiU. 

all been young children. In Erichseu's case the age of the 
patient is not mentioned, but it is spoken of as a hydroce- 
phalic child. Mr. Haward's patient was aged one year and 
seven months; the age of my first patient was two years and 
six monthsj and that of the case now reported was one year aod 
eleven months at the time he met with the injury. It will be 
noted also that a fall from an upper storey was the cause of the 
fracture in each instance. Head injuries caused in this manner 
are anything but rare in adults among bricklayers, joiners, and 
such as are employed on scaffoldings or in the erection of 
buildings, but no case, so far as I am aware, has occurred in an 
adult of simple fracture followed by a large collection of 
cerebro- spinal fluid beneath the scalp. An easy deduction can be 
drawn from these facts — that the elasticity and thinness of chil- 
dren's skulls permit or determine the injury upon which this 
rare phenomenon depends, whereas in adults the strong and 
firmly ossified calvarium cannot be driven in to a like extent 
without an accompanying laceration of the scalp. Hence, 
similar injuries in adults are compound, and may be followed 
by the escape of cerebro-spinal Quid through the wound, but 
never, so far as recorded cases indicate, by collections beneath 
the scalp. 

It is clear that in all sncb injuries the dura mater and the 
visceral arachnoid must have been lacerated, but is a wound 
stopping short at this point sufficient to cause so large an 
escape of fluid as has been observed in these cases ? I think 
not ; and I am inclined to believe that, had a careful post- 
mortem examination been possible in every caae where the 
escape of clear fiuid from the vault had been noted, some 
wound of the ventricular cavity would in each instance have 
been found. 

The snbarachnoid space, when irritated, rapidly pours out 
plastic lymph ; and fluid in quantity on the hemispheres, though 
met with occasionally in association with atrophied brain, is 
not, I believe, found as a result of inflammation or after frac- 
tures. A slight wound of the ventricles, however, would allow 
of a very free escape of clear fluid, such as has been noted in 
several compound fractures of the vault. 

The first case reported by me of a collection of cerebro-spinal 
fluid beneath the scalp was proved, by post-mortem examination 

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A Second Ctue of Fracture of the Shdl 97 

two yean after^ to have been caused hy a wound of the descending 
horn of the lateral ventricle, and in the case now recorded, to 
limilar in nature^ I have little doubt that the anterior eoran 
was woimded. In both cases the injuries were so severe that 
laceration of the brain to the depth of the veutidde was not 
improbable. 

In farther support of the view that when lai^ quantities of 
clear flaid escape through the vault the wound has reached the 
ventricle, I may again allude to the nine cases mentioned by 
Mr. Frescott Hewitt in his essay in Holmes' ' System of 
Surgery.' It is not a little remarkable that seven of these 
cases recovered, so that the nature of the injury was merely a 
matter of conjecture, but in both the cases where a post-mortem 
examination was obtained, an aperture into the ventricle was 
discovered. 

It is not necessary that the wound should, in the first instant, 
actually reach the ventricle, for it would appear that in the cases 
vbere post-mortem examinations were obtained, the outflow of 
clear fluid took place some weeks after the inj ury, in consequence 
of a softening process having extended to the ventricular cavity. 
Why, seeing that the visceral arachnoid must have been injured 
in these cases at the time of the accident, did not the fluid 
escape then or a few days after ? Again, if a wound of the 
inner layer of arachnoid were sufficient to give rise to the escape 
of watery fluid, surely this would be much more frequently 
noticed. Why is it not met with in every case of punctured 
fracture when the brain is wounded by the fragments or by the 
foreign body ? For instance, in the * Clinical Society's Tran- 
sactions ' for 1879, 1 reported a bullet-wound of the skull where 
the internal table had been driven back so as to perforate Ae 
dura mater and injure the brain. Why, in this case, did not 
cerebro- spinal fluid escape during the five days the man lived 
after the injury? It may be premature to state that in every 
case where watery fluid escapes from the vertex the ventricular 
cavity has been laid open, but all post-mortem evidence seems 
to point to this conclusion, whilst the view that the fluid escapes 
fnmi the subarachnoid space rests only upon conjecture. 



r 

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A CASE OF OSTEITIS DEFOBMANS. 



El C. J. STMOIfDS, M.S. 



As examples of this dUeose are not of. frequent occurrence, 
and as the present one exhibitfi a itriking malformation of one 
of the hones of the forearm, it has been thought worthy^ of a 
place in these Beports. Mr. Bryant has recorded a case in the 
Tolnme for 1877. 

The patient, Mrs. W — , whom I hare had under obserration 
for six years, is now sixty-nine years old. Excepting her 
father, no member of her family has, so far as she knows, 
suffered £rom any special disease. Her own three daughters 
are in good health, and except with these, she has never been 
pregnant. Her father suffered from "rheumatic gont," but 
lived to tbe age of eighty, his hands were mnch deformed, and 
he was lame. Mrs. W — ■ is quite sure that there was do 
bowing of the legs, and that her father's complaint was entirely 
different from her own; indeed, her descriptioQ of tbe malady 
justifies the nse of the term employed by her. There is 
espeoally no history of tumour or syphilis, either in tbe 
patient or her family. 

When about the age of forty-eight, without suffering any 
previous pain, and without any assignable cause, the left shin 
began to bulge forward. Under medical advice iodine was 
applied, but as this produced considerable pain it was discon< 
tinaedt Within a short period tbe right shin began to acquire 

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loo A Ca$e of Otteiti* Defortami. 

the same appearance. The gradual increoBe of the deformity 
continued to be the only symptom till aboat twelve years ago, 
when she began to experience aching pain in the right armj 
chiefly from the elbow to the wrist. This was frequently so 
severe at night, that rest was only obtained by hanging 
the arm over the edge of the bed. At that time she was 
occupied in household work, and did beudes a good deal of 
sewing. 

Eight or nine years after the bowing was first noticed in 
the legs, and soon after the aching pain began in the right 
arm, she noticed that the left arm began to "crook," and 
its movementfl to be impaired. Since this time the corvattire 
of the radius has increased, and the bone has gradually assumed 
the position it at present occupies, without ever causing her 
more than an occasional ache. 

Coincident with the pain in the right and the bowing of the 
left arm, the right hip became painful and prominent, and she 
states that even before this, her friends observed a limp in her 
gait. On ioquiring more particularly into the amount of pain 
experienced in these several situations, she states that in the 
right arm it was so severe as to render her insensible to 
slighter degrees. Five years ago, while undertaking the 
the duties of a cook, an ulcer formed on the left shin ; this has 
increased continually, and is now her most distressing com- 
plaint. She is unable to remember exactly when the pain 
disappeared from the right arm, hut it has ceased to attract 
attention since the formation of the ulcer. This arm is now 
free from pain, is strong, and exhibits no deformity whatever. 
The course of the disease has not been marked by any special 
feature, nor has any other joint become involved. For the last 
few years she has had occasional attacks of abdominal pain, 
accompanied by sickness, and has one or twice been very ill. 
At present there is nothing to indicate the nature of these 
attacks, the bowels act regularly, and nothing abnormal can be 
discovered in the abdominal viscera. 

At the present time (December, 1880} Mrs. W — is in 
fairly good health, and is still possessed of considerable enei^^. 
She recently made a journey to Swindon, and is only prevented 
from being more active bythe pain and inconvenience of the 
oloer. 

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A Case of OaieitiB D^ormatu. 101 

The disease is limited at present to the bones of the lower 
extremities and to the left radios. 

Both tibite are extenuvely thickened and boved forward, 
wliile the fibolse remain unaltered. The whole appearance 
correBponds exactly with the iUuBtratious accompanyiug Sir 
James Fagefs paper in the ' Med. Chir. Trana.' vol. Ix, pi. i, bo 
that ftirther description Beems unnecessary. The lower two 
thirds of the left femur present the same form of enlargement^ 
the thickening grsdnally diminiBhing upwards. This bone is 
slightly curved forward, so that when the limb is extended, 
while the patient is recumbent, the beel and upper part of the 
thigh are the only parts in contact with the horizontal. There 
is no sadden or bossy enlargement of these bones, the surface 
feeling only a little rough. 

The joints of tbia limb, with the exception of the ankle— the 
movement of which is impaired by the oedema Burronnding the 
ulcer— enjoy the fall range of motion. The disease in the 
right femur is confined to its upper extremity. The trochanter 
IB widened and its outline is ill-defined, but it is not more 
prominent than that of the other side. The limb is permanently 
rotated outwards, abduction in any position is impossible, and 
only slight adduction is permitted, while flexion to a right 
angle is free and unaccompanied by grating or pain. There is 
neither in this nor in any other joint further evidence of rheu- 
matic arthritia. The right leg is five eighths of an inch shorter 
than the left. 

The deformity which is the special feature in this case 
exists in the left radios, and is foirly well shown in the accom- 
panying drawing. The bone is enlarged and elongated; it 
measures dj-ths inches in length over the curve, while the right 
u dfths. It presents posteriorly a conspicaoos curve, gradually 
increasing in prominence ta about the junction of the lower 
and middle thirds, where it ends in a sharp ridge, round which 
curve the extensors of the thumb, the ulna remaining 
unaltered. The radins curves also forwards, taroiog the band 
into a position of complete pronation, so that the rotatory 
movements of the forearm are annulled. The extensor muscles 
form a slight rounded prominence in the middle third, having 
bllen towitrds the ulna, owing to tbe backward curve of the 
radios. 

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102 A Case of OtteitU Deformant. 

She is not aware that there has been any increase in the size 
of her head, but for future observation the following meaaure- 
ments vere taken : 

Circumference at level of middle of temporal fossa 21 in. 

From occipital spine to base of nasal bones 14 in. 

From mastoid process to mastoid process 9^ in. 

There is no curvature or ligiditj of the spine. There is an 
old united fracture of the right clavicle. 



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ON THE 

BHETJMATIO DIATHESIS IN CHILDHOOD. 

Bt JAKES F. 600DHABT. M.D. 



Thb foUowing paper has in it little that is novel. On the 
contrary, I would bespeak the attention of mj readersj because 
the subject is one witti whicli tbey must be quite familiar. 

Diatheses, vhatever may have been thought in times gone 
by, are not allowed to pass unchallenged now. But whether 
diatheses are realities, and whether there is such a thing as a 
rhenmatic diathesis or not, are questions which involTe far- 
reaching issues. 

For some years past I have been in the habit of making 
careful inquiries both in the out-patient room at Guy's 
Hospital and also in that of the Evelina Hospital for Children 
upon the parental sick bill of the children that have been 
brought to me. The facts that have been collected form the 
basis of this paper. 

X have no intention of conoeming myself with the facts which 
others have collected, I had almost said times already without 
number. I am not unmindful that the subject has andei^one 
repeated discussion, but were I to attempt to treat the question 
historically this volume would, I fear, not be able to contain 
the things that might be written. I shall only permit myself 
to say in limine as an index and reminder to those interested 
in the subject, and because articles in volumes of this kind 
are often foi^otten or fall unheeded, that the ' Qny's Hos- 

ogle 



104 On the Rheufnatii: Diatheiia in Childhood. 

pital Reports * hare already contained matter beariog opoa one 
or other branch of the rheumatic diatheais, by Dr. Hughes, in 
a " Digest of 100 Cases of Chorea," in Series 2, vol. iv, and by 
Dr. Pye-Smith, in an " Analysis of Cases of Rheumatism^ &c.," 
in Series 8, toI. zii. Dr. Pye-Smith, indeed, does not allow 
that there is sueh a thing as a rheumatic diathesis, but he shows 
that rheamatism is transmitted irom one generation to another 
in 33 per cent, of the cases, and hereditary transmission embo- 
dies a large part, though not the whole, of the idea which the 
term diathesis expresses. And I suspect that any differences 
of opinion which we may seem to entertain are more questions 
of the meaning to be attached to words than of the essential 
difference of things. 

After this it may appear to some that the proper point of 
departure for any observations I may have to mtjce wonld be 
to define the limits of the term " diathesis." But definitions, 
while they hare much to recommend them, have, on the other 
hand, an obvious disadvantage, that while they seem to clear 
the way, they often open up pitfalls which are very difficult, 
if not impossible to avoid, lu the first place, the views of the 
writer must be accommodated, which may or may not be a 
difficult matter ; and next the many points from which others 
may advance upon the subject must all be included — a task 
which is very certain to be one of considerable difficulty. 
Definitions for some must be comprehensive, for others exact. 
But the varjdng combinations which disease effects with con- 
stitutional build, in the changeful circnmstances of social life, 
if they allow of the one, almost exclude the possibility of 
the other. And with reference to the term diathesis iu parti- 
cular, it seems to me that to impose upon it the restraints of 
an ill-fitting definition is to do the subject but questionable 
service ; and to invite the criticism so rife just now that it has no 
meaning, I would say of it just what Dean Church says of 
civilisation — " It is, we all know, a vague and elastic word . . 
. . but it expresses a substantial idea, it marks a real differ- 
ence in what men are and can be." ' 

Now, in very general terms my idea of diathesis is this : a 
something represented by a certain bodily conformation, which 

I -Tbe Gift* o| CirtliwtoB.' By B. W. Church, M.A,, D.C.L., Ikva. 9t 
St, Paol'i. 

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On the Rheumatic Diaihetia in Childhood. 105 

u characteristic of its parentage ; is possessed of a vital tnachinery 
which tends to vork in a characteristic way ; and which in torn 
tends to transmit its methods of working to its progeny. 
Diathesis, therefore, seems to me to be equivalent to family 
strain, and so reading it, I should call hereditary geDios a 
diathesis, or rather a manifestation of one. The bodily form 
o{ the indiridoal is often a re-emhodiment of its antecedents, 
and its modes of working are characteristic. 

The "gentle life" which comes of good breeding, the 
Sohemianism apparently so ineradicable in many, even though 
freedom be sought carefully and with tears, are equally manifes- 
tations of a diathesis as much as are the qualities of a thorough- 
bred horse. Take any one of these sabstaative expressions of 
a diathesis, and it could be said of it, with tolerable accuracy, 
it comes of such a stock, and that it is liable to evolve in its 
working certain characteristic phenomena normal or abnormal. 

But I should not, as some would do, call such a disease as 
syphilis diathetic for many reasons, but chiefly because the 
disease is easily acquired ; when transmitted from parent to 
ofispring it wears itself out early in the second generation, and 
bansmission to a third generation is not known. 

In this sense, I propose to consider the rheumatic dia- 
tbens in children in the present paper. There are certain 
oonditioQB or states in children — I do not by any means exclude 
adolts from participation, but that I am not now concerned 
with them — which are found in associatioa with a rheumatic 
strain. These are acute rheumatism, heart disease, chorea, 
headache, night terrors, what I shall call crises gastriques, 
nocturnal incontinence of mine, some forms of moscular spasm, 
nervousness, &c. 

For the last three or four years I have been collecting 
evidence npon the question (^ the liabilities incurred by 
children of rheumatic parentage. Let us see with what results. 

I will first say a word,on the intetmty of the rheumatic strain. 
Various opinions are held upon this question, but upon the 
whole it appears that authorities are agreed that rhenmatism 
is capable of hereditary transmission, though not so strongly 
as many other diseases. From a large number of inquiries 
npon this point, however, it appears to me that there are few 
diseases which run more in families than it, Th? rcsolt* are. 



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106 On the R&etmatie Diatheri* m Childhood. 

I grant, often leas striking than those of phtliisis, for instance, 
to take, perhaps, the disease irbich all would grant is one of 
the most hereditary. But this is because phthisis will kill 
off a whole family one after the other, and such a devastation 
as that it is impossible to ignore. Sheamatism, on the other 
hand, while tainting all, will only maim or destroy, perhaps, 
one ; and the lesser rheumatic ailments are apt to elade notice. 
But examples of rheumatic family tendency might be quoted 
quite as marked as any consumptive one. For inatanoe, a 
mother who says that she has had rheumatism in her kneee, 
whose own mother has " rheumatic gout," and whose huaband 
has had rheumatic fever, has, at various times, brought her 
entire family of six children to me. The eldest, a boy of fifteen, 
has had rfaenmatio fsvsr twice, and has mitral regnifiitation. The 
second boy, aged tan, has had rhenmatio fever twice, and haa 
also mitral disease. The third, a girl aged eight, had mitral 
disease, and died in the hospital. The fourth, aged seven, bad 
rheumatic fever afber scarlatina, and at the end of two years, 
through which 1 watched her, there was good evidence of mitral 
thickening progressing towards constriction of the orifice. The 
pulse was irregular, the first sound rough, the second per- 
sistently accentuated, and the impulse forcible. The fifth, a 
boy, aged four, was laid up all one winter with rheumatism. 
And the sixth alone gave no evidence of rheumatism, a fact 
which perhaps couuts for less when 1 say that it died at 
the age of fourteen mouths of tubercular meningitis. The 
history of this one family would alone be enough to make one 
think very respectfully of the rheumatic diathesis and of the 
persistence of the rheumatic strain. Other facts all tell in the 
same direction. 

Acute rhewnatimi in children is in the majority of cases 
inherited. I have notes of forty-four cases, twenty-six girls 
and eighteen boys. Eighteen had what I shall venture to call 
a good family history. Seven more a moderately good one. 
In four the history of rheumatism was indifierent. In nine 
there was no history, and in six others the history is not 
stated. Two thirds, therefore, hare rheumatic antecedents of 
some sort. 

What I have called good, moderate, and indifferent histories 
of rheumatism may be seen by a glance at the euameratioQ of 



On the RAemuUie Diathttis in Childhood. 107 

cases given in &n appendix at the end of the paper. The 
prefix G. correBponding to good, M. to moderate, I. to in- 
different; R. atanda for rheamatic fever in the individual onl;; 
— indicates that there is no definite note on the snbject in mj 
notes; N. indicates that no history could be obtained, I may, 
however, say at once that a hiator; of rheumatic fever in the 
father or mother, or brothers or sisters, has been called good. A 
history of rheamatic fever or rheumatic gout in relatives other 
than the immediate progenitors counts for moderate, unless, as 
in one or two cases, there is a clear history of rheumatic fever 
in more than one uncle or aunt. 

I UQ by no means clear that in the group of moderates I 
have not underrated the inteniity of the family strain. This 
ii the group whioh ineludee grandparenta, and it appears to me 
that there is a rather frequent tendency towards atavism in the 
transmission of rheumatism j and the occurrence of atavism, if 
frequent, would be a strong point in favour of the propagation 
of the disease in conformity with the ordinary laws of here- 
ditary transmission. 

Under indifferent come all things denominated " rhen- 
matiam." But for this group I wish to say that some of these 
are probably rheumatic fever cases, which in the hurry of note 
taking have been s^led thus ambignously. Histories of vague 
rheumatic pains have been rtijected as meaning nothing, and 
idiere I call a complaint rheumatum it generally means some 
definite illness, though not long enough or definite enough to 
go as rheamatic fever. I must also say that as far as I have 
been able to keep to a strict use of terms, " Rheumatic 
fever " means usually in my notes an illness which has laid up 
the patient or relative for several weeks in bed. 

It ifl necessary to say all this, because such statistics as these 
ate ofleo met by the objection that " rheumatism " means 
oodiing. By excluding slight cases I have taken aU possible 
care that rheumatism shall stand for a definite illness. 

I come next to heart diteate in children. I have notes of 
187 cases, all of which have come under my own care. 
Poltowing the same lines as those laid down for acute rheu- 
matism, I find that forty^six cases had a good family history, 
ten a moderate, and seventeen an indifferent one, and in 
nineteen others the patient had had rheumatic fever. So tiut 

. „Gooj^lc 



108 On tie RAeumatie JHathetu in Childhood. 

ninety-two patients out of 187, or tvo thirds of the whole, were 
rhenmaticj and most of them rheumatic beyond any doubt. 

I thall aesnme, after what has gone before, that of the 
nineteen patients who had had rheumatic fever two thirds 
would have a family history of rheumatiBm, when the per- 
centage of cases which give a family history would be only 
very slightly lowered, being something under two thirds of all 
the cases. 

I have further divided the 137 cases more critically into two 
groups of rheumatic heart disease and non-rheumatic, which 
makes the rheumatic 'group somewhat larger. That is to say, 
ninety-six instead of ninety-two, because there are four cases 
which although wanting in definite history were rheumatic in 
all probabili^. Thus, one girl was subject to rheumatic pains, 
but had never been laid up, an amount of rheumatism quite 
sufficient in childhood to explain heart disease. Another child 
has a history of aching in the limbs, &c., and so on. 

It is, however, necessary to say that in sixty-seven csaes of 
rheumatio heart disease in adults there is less evidence of this 
persistent strain, but in adults the family tendencies are 
ofttimes forgotten, and the history is, on the whole, less 
reliable. It is obvious that in dealing with adiflts inquiries of 
this sort often come new to them, particularly in the lower 
classes, and at a time when, their parents being in many cases 
dead, the opportunity for gaining information has passed away. 
With children this is not so. In the majority of cases they 
are brought by the mother or some near relation, and two 
generations are within reach of inquiry which can give reliable 
results. 

An analysis of the sixty-seven cases in adults shows that 
twenty gave a family history of rheumatism, twenty-two could 
give none, and in twenty-five no mention is made of the 
point. 

Now, if two diirds of the cases of acute rheumatism give a 
history of hereditary transmission of that disease, and if 
nearly two thirds of all the cases of heart disease show similar 
antecedents, I think tbe facts are sufficient to justify the con- 
clusion, not only that rheumatism is capable of transmission— 
for that is already allowed by most men — but that it will be 

trvwioitted twice in vr&ey thne casea, and tbtt it is therefore 

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Oh tht Rheumatie IHathetii m Childhood. l09 

k Tery pTononnced strain. I tbiok there can be no doubt of 
tbis, bnt I do not think it is acted npon in practice. Let me 
take an instance. Life insnTance offices guard their policnes most 
strictly against anytbing of the nature of pbtbiBts, while there 
is not in the papers of some offices a single qaestion devoted to 
ascertaining the existence or not of a family taint of rben- 
matisio. I remember well looking over the papers of one wbo 
proposed to insure bis life in one of the weU'established offices 
of London. There was a strong rheumatic family biatory, and 
I searched in vain for any indication that this was regarded 
with any suspicion by the office in question. Yet I maintain 
that it is only proper and pmdent to pat an increased risk on 
such a life. 

Acute rheumatism is transmitted as acute rfaeamatism, if I 
may so express myself, with the accompanying disease of the 
heart in many cases. Witneas the forty-six cases of acute 
rheumatism witb £amily history in two thirds of tbem, and the 
foci that forty oat of ninety-six cases of. rheumatic heart 
disease were auto-rheumatic. But this is by no means always 
the case, and it is the varieties of the rheumatic manifestation 
which seem to me to be of special interest, and to which I 
would particalarly draw attention. 

In the first place, a rheumatic mother may transmit some- 
thing to the fcetns wbicb leads to congenital heart disease — at 
least, this seems to me very probable A'om the following cases. 
A mother had had rheumatic fever seven times (so she 
stated), and her child was born cyanoeed and witb a loud systolic 
bruit over the pulmonary area, leading one to think that there 
was probably some pulmonary steoosis with possibly a deficient 
ventricular septum. The child was still alive when I last beard 
of it, so that there bas been no opportunity of verifying the 
diagnosis. In a second case the father had bad rheumatic fever, 
and there was extreme cyanoais in the child, a systolic bruit 
at the apex and in the axilla, another over the mid-sternum, 
and another over the aortic valves. The nature of this case is 
uncertain, bnt it is probable that both mitral and tricuspid 
thickening exiated, and probably either aortio or pulmonary 
stenosis also. 

A third case has lately come under my notice. An infant of 
two montba old was brought to me in an extremely wasted state 

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110 On the Rheumatie Diathesia in Childhood. 

and Tei7 ansemiCjTwith the etatement that it had been so since 
birth. The action of the heart was rapid, and there was a load 
systolic bruit heard all over the precordial area. It was, bow- 
ever, more intense at the apex, and was heard londly in the 
axilla and back, There was no thrill either at the apex or 
base, and nothing that I could detect abnormal in the tricuspid 
region. The case was, I think, most probably one of mitral 
regu^tatiou. On questioning the mother upon her previoua 
illnessesj she told me that she had suffered from some Tei7 
severe fever when she was twelve or thirteen years old, which 
had kept her to bed many weeks, and in which her chief sym- 
ptoms were great pain, swelling in the joints, and mnch sweat- 
ing and difficulty of breathing. The difficulty of getting her 
breath she made the most of, indeed, confessed to Bponta- 
neonsly ; the other symptoms were only elicited by leading 
qnestions, but she was eqnally decided abont them when they 
were explained to her. I therefore think it probable that ber 
illness was an attack of acute rheumatism, and that the child 
waa BuSering from a rheumatic endocarditis of congenital 
- origin. 

This question of congenital rheumatic endocarditis has often 
been discussed, but whether ot not snch a condition occurs is 
certainly not yet one of the settled qnestions of pathology. 
It is not pretended that these cases are decisive, but they are 
to my mind strikingly suggestive. From this point of view I 
am somewhat doubtful conceming the unconditional truth of 
Dr. Bedford Fenwick's contention that cases of tricuspid stenosia 
are acquired and not, as usually held, congenital. I have, 
though not a believer in many conditions often considered to 
be congenital, always considered that when we find that mitral 
and tricuspid stenosis coexist the disease is probably con- 
genital, I am still inclined to adhere to that opinion for many 
reasons, but chiefly in this place because I believe that rheu- 
matic endocarditiB may be initiated in vtero, and when initiated 
any snbseqnent attacks of acute rheumatism in extra-nterine 
life, by intensifying the cardiac disease, would in many cases 
appear, judging only from symptoms, to be its cause. 

ApropoB of this opinion, let me next say that I think there 
can be little donbt that a rheumatic parent may transmit a 
something to the child which may, in the course of years, pro* 

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On the Rhaimatic Diathttit in Childhood. Ill 

dace definite Talvnlar disease — a tendency to chronic endo-. 
carditis ; I do not soppose that the valves are diseased at birth. 
Bat there is evidence to show that children of rheumatic 
paiantage are liable to become affected by permanent heart 
disease vrithoat having nndergone the process of acute rhea- 
matism. For instance, only the other day this case occnrred 
to me :— A mother brought her boy, of abont nine, for choreaj 
which he had had repeatedly, I inquired for rheumatism in 
&tlier or mother, but unsnccessfnlly. Bnt noticing that the 
mother was extremely ansmic, I questioned her concerning 
her relatives, and found that the maternal grandmother had 
had rhenmatic fever twice, and had beeu laid up six weeks each 
time. The mother had never had it to her knowledge, bnt I 
examined her heart and found a diffused impulse, thick 
grating first sonnd, with a short systolic bruit under the nipple; 
the impression given by the physical signs being that the 
mitral valve was thick and probably small. 

These cases are usually explained by the assertion, which is 
no doubt correct in great measure, that acute rheumatism is 
vciy obscure in childhood from the mildness of its attack, and 
that any child may have had it vrithont notice being attracted 
by any appearance of illness. A child complains of aching in 
its limbs, perhaps, nothing more, and is afterwards found to 
have heart disease. The interpretation put upon the fact by 
many is that the passing pains were due to the rheumatic fever 
of childhood, and the heart disease is at once the result and the 
eridenee of this. It may, perhaps, be thought a mere question 
of words, but I think it better not to call these obscure pains 
wbidi children suffer — quite insufficient in many cases to send 
them to bed — acute rheumatism. It is far better, I think, to 
say that the rheumatic taint leads to such symptoms, and in 
Uie same way as it causes chronic changes in the joints so it 
may lead to chronic changes in the endocardium, no acute 
endocarditis having been at any time present. Better far than 
to call a disease acute which has certainly never been so in 
any ordinary acceptation of the term acnteness, in order to 
square with the orthodox views of the causation of heart dis- 
ease. I am inclined to think, too, that the parallel I would 
draw between the chronic joint afi'ectiou and the chronic endo- 
carditis is closer than 1 have here stated it to be. Some years 



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11)2 On ifie Rheumatie Diaihetit in (Haldhood. 

■ agOj when more in the surgic&l wards tha& I am now, I made 
inquiries concerning the family history of a good many caaes 
of disease of the knee-joint, and 1 waa surprised aa well as 
interested to find that not a few patients bo afTected came of 
rheumatic parentage, yet in hardly any was there a history of 
prerioos acute rheumatism. 

I might, again, instance a case which occurred to me only 
the other day. I was asked by one of my colleagues to see a 
girl who had obstinate unilateral headache. I found that she 
was suffering from a synovitis of the knee of some months' 
duration, and her dark hair and extreme pallor at once suggested 
rheumatic tendencies to my mind. I inquired of her as to 
acute rheumatism, and she told me that till the attack of syno- 
vitis after exposure she had never had an ache or a pain to her 
remembrance. Bat, on the other hand, her father had died of 
heart disease, a comparatively young man, just over forty, when 
she was an infant; and one of her sisters had been in the 
liospital with rheumatic fever. Had I not strong reasons for 
considering that she was an example of the rheamatic diathesis 
which was working in her knee and now in her head? 

In former years it was taught that rheumatic synovitis 
differed from other forms of inSammation in being but rarely 
destructive, but in the widening knowledge which we are now 
acquiring on the subject of acute and chronic destructive joint 
disease in acute and chronic nervous disorders, that proposition 
will probably in the future fail to be established ; and although 
being in many cases an acute disease in a previously healthy 
structure, rheumatic synovitis, like other acute inflammation, 
will probably in a large proportion of cases completely resolve, 
yet rheumatisDi will have to take its place as a definite cause 
of cAronic joint disease, if not through acute synovitis, by the 
not less sure process of chronic thickening. And, to return 
to the organ more immediately under discussion, I believe it 
to be essential to the correct estimate of the various causes of 
valvular disease of the heart that we should learn to recognise 
more fully than is yet done the varied conditions which are 
liable to engender chronic hypertrophic or inflammatory 
changes in the valves. Here is one. The existence of mitral 
disease in a child is often the only eridence of a rheumatic 
strain apart from family history. A fair proportion of oases of 

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On the Rheumatic iHathetU in Childhood. llS 

mitral steuosia in adults are to be explained in this way, unless 
we take up the view held by some, which I do not think is 
tenable, that they are of congenital origin. 

I will take this opportunity of saying a word or two more 
upon this question of the congenital origin of mitral atenosis. 
I have alluded to it elsewhere,' but the fact with which I am 
dealing now allows of its reintroduction. I just now spoke of 
the probable occurrence of intra-uterine endocarditis. I think 
it probable that given such a condition children may not in- 
frequently be born with some defect of the valves of this sort, 
which may be slowly accentuated in after life either by other 
attacks of rheumatism or by the ordinary wear and tear of a 
damaged and imperfect valve. 

Dr. Peacock has ably contended for the frequency of 
valvular disease produced in this way, with this difference only 
that for intra uterine inflammation he would substitute mal- 
formalicm. To the extent I have indicated I am prepared to 
admit the existence of congenital diBcase, but I am not pre- 
pared to admit that mitral Btenosis is congenital as mitral 
stenoMS except in a small proportion of cases. And the ground 
of my objection is, 1 believe, unanswerable. It is this that in 
all my cases of heart disease in children assured mitral contrac- 
tion is rare, and even doubtful cases are but a small proportion 
of the whole. The figures are as follows : 

Bhemnfttjc heart dueu« . . . .96 

Non-rhenmatic >• • ■ • ^1- . 

Heart diieaBa in the coaree of acnt« rhcnmatiim • 23 

Chorric heart dite«w . . . 6 



Of these cases five only were certainly cases of mitral con- 
traction, judged, that is to say, by pnesystolic or diastolic bruit 
and thrill; seventeen others have s ? against them. The valve 
was probably thick, but the physical signs of contraction were 
not distinctive. Some had a hoarse first sound, others an 
occasional slight thrill, and so on. The remainder, with the 
exception of eight cases which were cases of aortic disease, were 

' " On Annmia hb a Came of TalTiilar Diaeaie," ' Lancet,' vol. i, 1S80. 
' In order to avoid any conftuion of figures I hHre Vept the indiiridoal groups 
of MM* diitinct, both in what has gone before and in that which followt, 
VOL. XIV, 8^ 

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Il4 On the Rheumatic Diatherit in Childhood. 

examples either of mitral regurgitation (114 cases] or of altera- 
tions in quality of the first soond with displacement of the 
impulse, ftc. Now, I think these facts admit of but one inter* 
pretation, both for constriction of the mitral and also of the 
aortic orifice, viz. that pronounced congenital imperfectionB caa 
0DI7 exist in a small proportion of cases. Otherwise we onght 
to detect more indications, even if slight, of the existence of 
disease in early childhood than we do. But, as a fact, mitral 
regurgitation is the common form of heart disease in childhood^ 
and it ii not till the a^ of work and strun, from the age 
of fifteen upwards, that aortic disease in any form, and 
mitral constriction, begin to appear as common afitections. 
There is, however, a class of cases of no inconsiderable magni- 
tude which admits of doubt as to the exact nature of the dis- 
ease. I allude to cases in which the first sound is thick, 
perhaps with an occasional short systolic bruit, generally with 
a too forcible and a difiiiaed impulse, and some irregnlarity. 
These cases no doubt may he construed as examples of slight 
Sickening of the valve of congenital origin, and as being the 
cases which will eventually become contracted mitrals of pro- 
nounced form. I confess I do not think so, because I have had 
now many opportunities of watching such cases for many 
months, and the physical signs alter and improve so mnch 
under persistent heematinic treatment that I believe moat of 
them are really due to abnormal muscular action, and not to 
the thickening of the valve. Sach children are generally pale, 
and often excitable and nervous, and arsenic and iron by 
improving these symptoms moderate the cardiac ones also. At 
the same time I believe that if these cardiac symptoms peraiat 
for any length of time they are of themselves efficient to 
originate endocardial thickening — chronic iufiammation of the 
endocardium, hypertrophy of the endocardium, or whatever we 
may choose to call it — and thus to lead to mitral constriction 
in the course of years, as surely as chronic urethritis leads to 
stricture, and this without any necessity for invoking the aid of 
congenital malformations. This is not merely an interesting 
speculation upon the etiology of valvular disease of the heart, it 
is a hypothesis which if true has practical bearings, the import- 
ance of which it would be difficult to over-estimate, 

D,91,zecl.yGOOglf 



On the Rheumalie D'lathetit in Childhood, 115 

Chorea is another evidence of rheumatic strain. I should 
liave felt some diffidence in adducing aa^ evidence on this 
point as I had thought that all of us were quite sufficiently 
assured of it. But since no leas careful an observer than Dr. 
Stui^es, of the Onnond Street Hospital, disputes it, perhaps 
the question may stiU be considered an open one. Dr. Sturges 
disputes the rheumatic origin of chorea on this ground, that 
only a small proportion of choreic children have had acnte 
rheumatism, and to the criticism that any attempt to settle the 
affinities of chorea is valueless which does not take into account 
inch family proclivities as exist, be replies that we do not as 
yet know the proper share of rheumatism that is to be accorded 
as an average to each family. 

It may be admitted that there are many difficulties in the 
way of accurately tracing such a disease as rheumatism in 
fiimilies, but these are by no means insuperable, and I believe 
as much can be said of rheumatism as of other strains, that 
some families are markedly rheumatic, while in others no 
history of rheumatism can be obtained ; and it seems to me 
sufficiently obvious that if there is any truth at all in the 
doctrine of heredity this must be so, unless, as is contended by 
some, rheumatism is a disease which is easily acquired. 

Prom some observations I have made upon this point, how- 
ever, I believe that taking 100 patients consecutively, without 
any selection, about 80 per cent, will be found to give some 
history of rheumatism in close relatives — using the term 
rheumatism in a comprehensive way — and if we restrict it to 
illness which has confined the patient to bed with pain and 
■welling in the joint for a period of weeks, it becomes of 
course much smaller. I see no ground therefore for supposing 
that acute rheumatism is readily acquired. If it were it 
ought to appear more indiscriminately than it appears to do. 
Having said this I may now add that a careful inquiry into 
family history seems to me to show incontestably that acute 
rheumatism and chorea are so frequently found in the same 
family as to prove a relationship to each other. 

The Bummary of the facts at my disposal is as follows the 
notes of the cases are given in an appendix. 

I have 81 cases, 57 of them in girls, 34 in boys. 



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On the BAeumatie IHatketU in Childhood. 

Auto-riieuiBmtie onlj 
Aato-ibeumitic, witli tuaHf luitai; 
Fainil J iMoTj ooly 
Gontj funil J hiitoiy 
NotttBtod 



81 

It may fiirther be atated that twentf-thiee of the casee had 
permaneDt mitral diseaBe. In three others there was qoea- 
tionable disease, tiro had aortic disease, and one both aortic 
and mitral disease. Two of the mitral cases had a presystolic 
bmit. A history of firight is given in fire cases, but in all of 
them there vas either a history of prerions rhenmatio ferer in 
the patient or evidence of family taint of rhenmatism. 

Is it only a coincidence that two thirds of the cases have a 
rheumatic taint of some sort, viz. exactly the same proportion 
as was found in the cases of acute rhenmatism and rheumatic 
heart disease previously given, and as Dr. Duckworth obtuued 
for the rheumatic origin of constricted mitral ? 

The position I take with regard to chorea then is this, that 
in two thirds of the cases it has close rheumatic relations, but I 
do not think it is always rheumatic by auy means ; the remain- 
ing third of the cases is a good margin for the working of other 
causes, of which probably mental shock may count as one ; 
various forms of aberrant nerve functions in the progenitors, 
such as epilepsy, neuralgia, as others ; gont as another ; and 
probably minor traits, which in the course of descent become 
gradually intensified till they culminate in chorea, but which 
on looking back present no sufficiently decided type to justify 
the allotment of a particular name. 

Nightmart, or night terrort, stands next upon my list as a 
condition which is liable to occur in rheumatic children. This 
is a very common affection, and naturally enough I have not 
taken such careful notes of these cases as I have done of heart 
disease, chorea, ftc. ; but I have notes of 87 cases, 21 boys and 
16 girls — 17 of them, 13 boys and 5 girls, had a family 
history of rheumatism, 5 others came of nervous or neuralgic 
stock, and in 8 the point was not inquired into. In 7 there 
was no history of rheumatism of any kind, I may also add 
that only 8 of the 87 are noted as rachitic 



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On the Rheumatie Diathttu in Childhood. 117 

Beadaehe. — Obstinate hesdaclie in children ia freqaeutly 
found in rheoiuatic families. I luve notes of 88 such cases. 
Twenty-three of them were of rheumatic stock, 5 of epUeptic, 
5 showed no abnormal taint. With some of these there was 
associated an intractable antemia. 

Antemia. — Acute rheumatism in the adult has been shown 
to be associated with a deficiency in the corpuscnlar elements 
of the blood, and there is a Large group of cases of anaemia in 
childhood associated not with rheumatism itself but with 
the rheumatic strain, I am inclined to think, farther, that it 
is more common in girls than in boys, and in those of dark 
rather than those of ligbt complexion. But this is opposed to 
what is generally tanght concerning acute rheamatiam. 

Newo-miucalar derangementt form another important group 
of cases found in those of rheumatic strain. Irregularities 
of muscular action, other than chorea, muscular spasm, &c., 
of which I may mention some cases of cervical opisthotouoi, of 
torticollis, tetany, muscular tremors, cesophagismos and stam- 
mering, incontinence of urine, felicitously termed by Sir 
James Paget the stammering bladder, also constitute a liability 
attached to rheamatism, and last, but by no means least, I 
would aUode to a state of irregularity of bowels, which seems to 
me to be of very much more interest than such a common 
place incident might at first sight appear. There are a 
number of children seen in the out-patient room of whom 
the tale is that they have frequent attacks of severe abdominal 
pain, the motions being loose and quickly succeeding a meal. 
Sometimes it is said of such children that as fast as they est 
the bowels act. Now these are symptoms which are attached 
to tabes mesenterica, and at first I was inclined to believe them, 
when persistent, to convey this indication. Of late, however, I 
have come, I think, to recognise that some of them are of 
rfaeamatic origin or, to put it more generally, are associated 
with a rheumatic strain, and that the symptoma are due to an 
abdominal neurosia. It is a condition which occasionally 
persists to adult age, and very inconvenient the affection is. 
I have an out-patient who comes to see me occasionally, very 
nervous be calU himself, but his chief trouble is that his boveU 
a^ upon the slightest excitement. 

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118 On the Rheumalic Diathesis in Childhood. 

We are all familiar with tKe occasional maDifeatation of this 
form of nervouB discharge, nnder the influence of great fear, 
and so on. But my point is this, that what occasionally 
occurs as an acute intestinal convulsion also presents itself as 
a chronic convnUive disease, an abdominal epilepsy or paralysis 
agitana may we call it, and as such requires recognition and 
treatment. 

I have already alluded to the interesting refleotionB which 
arise by bringing into juxtaposition the acute joint affection of 
acute rheumatism and acute nerve change, and the chronic 
joint affection of chronic rheumatism and ohronic nervous 
change ; it does not diminiah this interest to find that these 
abdominal affections allow of a similar grouping, and that 
while ataxic locomotrice has its well known criaes gastriques, 
the rheumatic strain has also an abdominal spasm or con- 
vulsion, such as I have described. 

Well, then, a number of children are brought of whom the 
mothers only complaint is, that tbey are " so nervous." Now, 
this sometimes means that a child is choreic, but more often 
no more than that it is unnaturally timid. Perhaps it will 
scream if left in bed in the dark, or if asked to go upstairs by 
itself in the dark. Sometimes it is that at games the child 
becomes so morbidly excited that it is quite exhausted and ill 
afterwards. All these things point to excessive nerve discharge 
for abnormally slight stimuli. The symptoms are well com- 
prised, I think, in the mother's term "nervous;" and such 
conditions I say are prone to occur in children whose parents 
or relatives suffer from rheumatism. 

I will allude to the cutaneous affections of the rheumatic 
child, only to say that erythema nodosum and psoriasis are not 
uncommonly evidence of the parentage of the child. Thus in 
twenty-nine cases of erythema nodosum, nineteen were rhen- 
matic, five were not, and five others were not interrogated upon 
the subject. Thus here again we have cutaneous affections in 
the course of rheumatiam which either by their course or 
associations suggest their nervous origin. 

And now let us summarise and see to what our facts lead 
as. 

I have endeavoured to show that parents who have had 
rheumatic fever transmit to their offspring a something, s eon- 



On ike Rheumatie DiatlieHt in Childhimd. 119 

BtitatioD, irhicli tends to sliow itself in variouB mja ; sometimes 
bj aeate rheumatism; sometimes by the slow production of 
endocardiiJ thickening and vslTolar disease ; sometimee by bad 
headaches ; sometimes by obstmate antemia ; sometimes by 
irrepnlaiities of muscnlar action, such as chorea, occasionally 
by epilepsy, by abdominal conyulsion, or perhaps it may be as 
veil to adopt Cbarcofs term as a general ooe, and call all such 
eriaea gastriqnes, sometimes by a more general but persistent 
low tone of nerrons system, snch as may happen temporarily to 
any one vhen below par, but is then speedily recovered from. 

As I look over my notes, and one by one the varied affections 
which occur in rheumatic families are filled in, the picture takes 
the oatline, hasy as it ebonid be, but still an outline of what baa 
been called of late years by Dr. Edward LiTeing a nerre storm ; 
and when we ^further call to mind that cases of acute rhea- 
matum are on record which have been intimately assoriated at 
Uieir onset with mental shock, the neural phenomenon of 
hyperpyrexia, and so on, there is no small ground for the 
view diat rheumatism is engendered by, or engenders, a state 
of nerrouB instability. It is nervous in the mnltiplidty of its 
forms ; it is nervous in its associations \ it is nervous in its 
points of attack ; it is nervous in its methods of attack, in ita 
course and progress ; and it is nervous in ita treatment. And 
although the most striking phenomenon of acute rheumatism, 
the acute synovitis has no very evident connection with nervous 
instability ; although we can as yet say but little, say nothing, 
of the nature of the process, I have already said in anticipation 
we know as a fact that other acute inflammatory processes are 
intimately associated with lessening and destruction of nervous 
influence ; and little as we know of the nature of the bond 
which exists between them and the destmctive joint affections, 
acute and chronic, which occor in snch diseases as myelitis 
and ataxic locomotrice, the fact of their association is among 
the possessions of pathology. 

The neurotic origin of goat has always had numerous ' sup- 
porters. Surely, if so, rheumatism may have also ; and even 
osteo-arthritis has many points in its history and associatisna 
which favour the opiuion that it too is of neurotic origin. 

I am even inclined to go further, and to say that the study 
pf these diatheses sn^ests that gQut, rheuniatism, and osteo* 

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120 On the Rhetmalic Diathetu in Childhood. 

arthritis, although, no doabt, distinct in the individual, are all 
first cousins to each otherj and that they are very possibly 
modifications or varieties of some common ancestral less speci- 
alised type, irhich in the process of evolution either of the 
disease or the family has given rise to all. 

It is not, however, with such a speculative subject as this 
that I would end this paper. There are many points of the 
greatest practical moment involved in the question I have 
attempted all too crudely to discuss. I must content myself 
with touching only upon one, and that one I may call the 
beginnings of heart disease. 

I have given facts to show that two thirds of all the cases of 
heart disease in children are of rheumatic origin. I have 
further given evidence for the belief that rheumatism is one of 
the family of neuroses ; and if soHhcn heart disease may own in 
many cases a nervoas origin. Let us go to work with this in 
view and what do we find ? Why, that there is clinical evidence 
of disturbed cardiac action in all sorts of cases of the so-called 
functional nervous disease. Not evidence of pronounced heart 
disease, were it so there would be less need to call attention to 
it, the fact would be too patent, but evidence of muscular irre- 
gularity; displacement of the impulse; abnormal quality of 
sounds ; occasional and temporary mitral bmits, and so forth, 
which mutt indicate increased wear and tear to the organ con- 
cerned. Let such a condition go on, as it does often, if not 
treated, for months, and is it not likely, to say the least, that 
thickening of the valves will be slowly engendered, which when 
started is difficult to arrest ? But on the alert to recognise the 
slight traits of habit and of manner — the pallor, the neuralgia, 
&c., which betoken what I have ventured to call a diathesis, and 
its attendant risks, those who have the medical charge of families 
are able to arrest by timely treatment these earlier functional 
diseases of the heart and avert the production of permanent 
valvular disease. If any other incentive to vigilance were neces- 
sary I would say that the careful observation and retxird of 
scries of snch cases would form a most valuable contribution to 
the etiology of heart disease, which, as all must know, is a sub- 
ject than which hardly any other is more vital from the fre- 
quency of its occurrence, or more interesting from the many 
problems it offers for solution to the intelligent mind. 

D,gt,zec.yGOOglf 



On the Rheumatie Diathesu in Childhood. 



APPENDIX. 

I have tboQght it well to add here a short note of all the 
cues of acute rheumatiam, heart disease, and chorea, npon 
vliich my conclasions are based. The prefix attached to each 
case indicates the relation to prerions rheumatism ; G = good 
bmily history ; M = moderate family history ; I = indifferent 
family history; R = rhenmstic fever in the patient only; 
N = tbsence of history. Imperfect notes are indicated by — . 

1. Acute Rheciutibh. 

I- Qirlj aged 6. Mother rheumatic in head, shoulders and 
TOsta, Heart normal. 

M. Boy, aged 8. Maternal grandfather has rheumatic gout. 
Heart normal. 

G. Girl, aged 9. Father has had rheumatic fever. Heart 
toimds thick ; impulse external to nipple. 

G, Boy, aged 9. Mother has had rheumatic fever. Heart 
normal. 

— . Oirl, aged 8^. Family history not stated. Heart normal. 

—■ Boy, aged 12. Family history not stated. Heart normal. 

G. Girl, aged 4. Father died with rheumatic fever and heart 
diKBK. Rheumatic fever came on after scarlatina in patient. 
Heart {?). 

B. Girl, aged 3^. Sister has night terrors. Baby brother 
convulsion. This child has rheumatic fever after scarlatina. 

6. Boy, aged 7. Mother has had rheumatic fever. First aoand 
thick. 

Q. Girl, aged 8. Mother has had rheumatic fever three 
times. Heart's action very rapid ; no bruit or displacement. 

G. fioy, aged 3^. Sister bad contracted mitral under me; 
since dead. Heart normal. 

M. Boy, aged 9. Paternal grandfather has gout. Father 
bu " rhevtmatism," but never laid up. Heart normal, 

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123 On tie BheBmaHe Diathetig in ChUdhooi. 

N. Boy, aged 3^, Family hiBtory noae. First Boand pro> 
longed. 

G. Girl, ftged 10. Mother has had rheumatic fever. Child's 
second attack. Heart hypertrophied and mitral incompetent. 

G. Girl, aged 3 months. Mother had rheumatic fever. 
Heart normal. 

N. Boy, aged 8. No family history of rheumatism. Heart, 
systolic apex bruit. 

G. Boy, aged 6. Mother has had rheumatic fever. Heart 
normal. 

I. Girl, aged 6. Father subject to " rheamatiBm," never laid 
up. Disease came on after scarlatina (?). 

M. C^l, aged 4. Tvo maternal uncles have had rheumatic 
fever. Heart uormaL 

I. Girl, aged 12. Mother has had rheumatism. Heart 
normal. 

G. Boy, aged 8, Mother has had rheomatic fever. Heart's 
action fondUe. 

M. Boy, aged 2^. Maternal grandmother has had rheumatic 
fever. Heart normal. 

G. Boy, aged 10. Father has had rheumatic fever. Heart 
normal. 

M. Boy, aged 4. Paternal uncle and maternal uncle have 
each had rheumatic fever. Heart's impulse diffused, irith mitral 
systolic bruit. 

M. Girl, aged 8. Mother has been subject to rheumatics 
sinee childhood. Heart normal. 

N. Girl] aged 6. No family history. Heart normal. 

— . Boy, aged 8. Family history not stated. Second attadc 
associated with purpura and mitral regurgitation. 

G. Boy, ' aged 2, Mother has had rheumatic fever. Heart 
normal. 

N. Girl, aged 10. No family history. Heart doubtfol; 
sounds muffled and thick. 

G. Girl, aged 6. Father has had rheumatic fever. Heart 
normal. 

G. Girl, aged 4. Paternal grandfkther and maternal annt 
have had rheumatic fever. Mother has had rheumatica, but 
never laid up, and father also. Her ovn sister has pains in her 
limbs, and a double murmur. 

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On the Wieumatic DiathesU m Childhood. I3S 

— . Gill, aged 8. Family history not atated. Heart nonnal, 

£. Girl, aged 6. No family history. Acate rheumatiBm after 
fright ? Heart normal. 

G, Girlj aged 11. Her mother died of heart disease, and her 
brother has had rhenmatic ferer. First sound thick. 

(t. Girl] aged 6. Mother had chorea when pregnant with 
this child. This child has had chorea. Uhort, soft systolic apex 
broit. 

N. Girl, aged 8. No family history. Heart nonnal. 

~. Boy, aged 7\. Family history not stated. Heart normal. 

R. Girl, aged 5. Family history not stated. Ilhenmatic fever 
t&a searlatina, 

G. Girl, aged 18. Father was laid up a long time with 
rheumatism. Heart normal. 

I. Boy, aged 12. Mother has had rheumatism. Heart normal. 

N. Boy, aged 12^. No family history. Heart normal. 

M. Girl, aged 4. Paternal grandfather long laid up with 
Theamatism. Heart normal. 

N. Girl, aged 7. No family history. Heart normal. 

G. Girl, aged 11. Mother had rheumatic fever. This child 
hu mitral disease and pericarditis. 



3. BnxCHATic Heakt Disease. 

M. Boy, aged 8. Mother laid up once for a week with rheu- 
matism daring a confinement. Patient laid up with rheuma- 
tism a year ago for two or three weeks ; now has frequent pain 
in all his joints. Heart's impulse diffused alt round the nipple, 
with systolic thrill in fifth and sixth spaces ; action very rapid; 
first sound accompanied by short, loud systolic bruit, audible in 
axilla and back. 

N. Girl, aged 9. Subject to rheumatic pains, but never laid 
up. No family history of rheumatism or gout. Dark aspect. 
Cardiac impulse in fifth space outside nipple. Heart's action, 
irregular ; systolic bruit at fourth interspace to left of sternum. 
Slight systolic roughness over the aortic valves. 

I. Girl, aged 6. Complains much of pains. Heart irregalar. 
father has rheumatics. 

H. Oirl, aged 8. Complains of cough. Heart's action irre- , 

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124 On the Rheumatic Diathent tn Childhood. 

golar, and occasionally two short beats followed by a short 
paase ; no brnit ; second soond very accentuated over the pul- 
monary cartilage ; impulse normal in position, bat hearing and 
forcible. Mother rheumatic, and father crippled by it so that 
he walks on crutches. Sister has it in feet. 

R. Oirl, aged 8^. Had acute rheumatism seven weeks before 
her attendance. Pnecordial dulness increased; impulse low 
down and extending outwards into mid-axillary line. Slight 
thrill in ensiform cartilage region. Load systolic brnit 
extending into axilla and back. No family history. 

I. Girl, aged 8. Fain in left side for twelve months. Pne- 
cordial dulness increased ; impulse forcible, Tertically below 
nipple in fifth space ; no bruit. Maternal aunt has rheumatism. 
U. Girl, aged 11. Had rheumatic pains, but neTer laid up. 
Chest prominent in front. Heart's impulse forcible and ex- 
teroal to the nipple. No bruit, but a thumping and vibrating 
action of heart with irregularity. Father subject to pains in 
' the limbs, and mother laid up eighteen months with " rheumatic 
fever and gout." 

I. Girl, aged 11. Complaint of headache. Loud mitral sys- 
tolic bruit. Said never to have had rheumatism herself, bnt 
father has rheumatism in his legs. 

M. Boy, aged 9. Has had three attacks of rheumatic fever. 
Heart's apex in sixth interspace an inch outside the nipple over 
an area of one and a half by two inches. Systolic murmur at 
the apex, in aulla, and between the scapulie. Maternal gnuid^ 
father subject to rheumatiam ; paternal tincle has had rhea- 
matic fever. 

O. Girl, aged 12. Extreme cyanosis. Quite well till five 
years ago, when she had scarlatina j since then she has always 
been weakly, with pain in her chest, and for two or three years 
she has been getting blue. Heart: apex beat diffused, but 
most marked at normal spot, slight thrill at apex. Systolic 
apex bruit fading in intensity rather quickly towards the 
axilla. Lood systolic bruit over the aortic valves, third costal 
cartilage, mid-sternum ; over mid-sternum, third rib level, is a 
loud, long, whiffing bruit, much louder than that over the aortic 
region, and heard all over the left side. No venous pulsation 
in neck. Her father has had rheumatic fever, and was laid up 
» long time. Diagnosis : (?) Tricuspid bruit, with regurgitant. 

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On Me Rhettmatie Diathetis in Cfaldhood. 125 

nitn], or aortic systoUc, or congenital absence of part of the 

G, "Boj, aged 6J. Rheumatic fever two months ago. Dif- 
fbied impolse, with slight thrill ; apex in third space ; a local 
ijttolic bruit at base. Father has had rheumatic fever. 

6. ^rl, aged 11. Subject to rheumatic pains in her joints. 
Im{nilae di£Exised ; apex beat within and without the nipple ; 
Gnt sound a prolonged thump; action irregular. Father very 
Rolgect to rheumatism, and several of his ^mily have had 
hewt disease. 

6. B07, aged 10. Qradual wasting for twelve months, with 
rnnch TiBible pulsation. Pale. Heart dulness large, impulse 
diffued; sounds lumpy; second sound loud. Mother had 
iheninatie fever while nursing child ; ill five months. 

G. B07, aged II. Frequently has pain all over him, and 
goes off into a faint. Heart's impulse diffused all round the 
nipple ; there is uo bruit, but the first sound is particularly 
thii^ and mufSed at the apex. Impulse heaving ; action 
rather irregular ; second sound loud. Father has had rheu- 
matic fever. 

I. Girl, aged 10. Six weeks ago had erythema nodosum. 
Complains of palpitation. Is overgrown. Heart's impulse 
difiiued in fifth space to half inch external to nipple. Action 
irregular; sounds thick; no bruit. One or two of family have 
" rheumatism." 

G. Girl, aged 9. Headache six weeks. Heart's impulse 
fbrdble, diffused, and long, with an occasional short bruit at 
apex. Mother has been laid up in bed with rheumatism for 
three months. 

M. Qirl, aged 8. Cough complained of. Systolic bruit at 
spex. Maternal grandmother had rheumatic fever. 

G. Girl, aged 11. Very pale. Impulse very diffused in 
fonrth and fifth spaces outside the nipple. Short systolic 
bruit with loud ringing second sound. (?) Hypertrophy with 
dilatation and adherent pericardium. Mother has bad rheu- 
matic fever and has heart disease. 

I. Girl, ^ed 6. Has cough. Reduplicated second sound at 
ipex, both on auscultation and to touch. No thrill and no 
pnetystolic bruit. Maternal grandfather and great aunt 
subject to rheumatism. 



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126 On the Skeumatie Diatkeiia in Childhood. 

I. B07, aged 4. Poorly for last six months and casting. 
Dark aspect ; anEemic. Impulse of heart in fifth space ver- 
tically below the nipple. Loud systolic bruit all orer tbe 
front of heart, but londeat at the base ; audible behind over the 
Tertebra prominens. Apex bruit (?). No rhenmatism in 
fiunily but gout on father's side. 

R. Girl, aged 11. Rheumatic pains in joints with sweUing. 
Heart's impulse in fifth apace under nipple. Load systolic 
mnrmnr audible posteriorly. 

It. Boy, aged 7. Systolic bruit at apex with occasional 
double pericardial friction sound and pleurisy (?). Impnlse 
diffused outside the nipple. No family history. This boy had 
rheumatic ferer two years and a half ago; was ill a long time. 

G. Boy, aged 6. Short breath for a few days. Heart's 
impulse forcible, external to the nipple and below sixth rib. 
Pnecordial dulness large. Systolic apex bruit in axilla and 
behind J systolic bruit also; (?) diastolic over the mid-sternum. 
The boy was iu the hospital three months before for rheumatic 
fever. Father has been laid up with rheumatic fever. 

G. Girl, aged Sj. Cough for about a fortnight. Bruit; 
harsh, short and systolic from mid-sternum upwards to lefl. 
Mother baa been laid up with rheumatic ferer for three 
months. 

G. Boy, aged 4}. Has had a bad cough for some mouths. 
Heart's impulse difTused, external to nipple. Action irregular, 
first sound at apex long. Mother has had rheumatic fever, 

H. Girl, aged 11. Fain in side and wasting. Loud local 
systolic bruit, with a questionable systolic at the impulse ; 
loudly systolic behind. Has had rheumatism several times. 
No fiiimily bistory of rheumatism. 

R. Girl, aged 8. Has always been delicate ; rheumatic pains 
about her for a month. Increase of epigastric pulsation, and 
also of impulse at nipple. Area of dolness not increased. 
Action regular. No bruit. Mother has had rheumatic fever, 

I. Boy, aged 8. Cough. Fain in the heart. Wasting. 
Impnlse vertically below the nipple. Systolic bruit at apex 
and away towards the ensiform cartilage. Action regular. 
No history of either rheumatiBm or gout in parents, but grand- 
father had goat and died of it. 

I. Girl, aged 6. Wasting, "goes so yellow." Heart's 

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On tht Bfteumatie Diatherii in Ckildhood. 127 

impolM diffhaed. Short syBtolic bmit after the fint sound and 
in iddition to it. Paternal grand&tlier had gout and all 
patvual nnclea. No rhenmatiHta knovo. 

I. Qirlj aged 10i> Rheumatic pains. Hearf b impolae 
diffnaed to l^ of nipple ; fint aoond prolonged and blowing. 
She haa had rheumatic fever. Hei father has been sulgeot to 
rhenmiitiam} bat haa never had "the fever." A Hubaequeut 
note to thia eaae recorda the presence of pnesyBtolio bruit and 
thiilL 

6. Boy, aged .11. Mother had rheumatio fever when she was 
nx. Ilearffl impnlse ia in the fifth interspace vertically below 
the nipple. Much too foroiUe and occaaionallf murmuroua, 

0. Oiri, aged 11. Father had rheumatic feverin 1860. The 
patienfa dlder brother has had rheumatic fever. She haaofien 
complaiBed of "paiiu." Sheiaa dark thin girl with violent 
palpitation going on. The hearf a impulse is diffnaed in the 
fmrth, fifth, and sixth spaces, both in and outside the nipple 
hue. The sounds are thick but there is no hrnit. (?) Adherent 
pericardium. 

R. Qirl, aged 6. Family history not mentioned. The child 
had acute rhenmatiim last year. The heart is large ; there is 
a loud systolie bruit in the axilla and back. 

R. Girl, aged 12. Family history not mentioned. Has had 
acnte rheumatism twice. Heart lai^; loud systolic bruit 
heard all over the chest and back. 

G. Girl, aged 4 months. Mother has had rheumatic fever 
seven times. The child haa been blue from her birth. Heart's 
action qniet. Action regular. No thiill. There ia a short, 
hanh systolic bruit, loudest between the nipple and atemnm 
over the fourth rib, but audible at the nipple and at the stemnm. 
Second sound accentuated at the base. 

G. Boy; aged 6J. Father had rheumatic fever twice. 
Mother had rheumatics in her knees for five weeks. Heart's 
action quick; impulse forcible and vertically below nipple. 
I^t sound long but no bmit. 

1. Girl, aged 9. Mother "rheumatio" but never liud up. 
She hat suffered fVom abdominal pains at times, and haa had 
pains all over her for a week. Much pallor. Heart-'s impulse 
diffased. Pericardial rub over all the precordial region, and a 
looaliied syattdic apex t»nit. 

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138 On the lihetmuatc IHatketU in ChUdhood. 

B. Boy, aged 6. Funily history not mentioaed. Quite veil 
till two months ago, when he had pains in his back and limbs. 
Latterly he baa had swelling of the lege. Much pallor. Pne- 
cordial dnlaess extensive. Impulse diffused. Endocardial 
fremitus communicated to the surface. Load masical ayatolic 
bruit at the apex in axilla and back. Second sound redupli- 
cated over pulmonary artery. No aortic or tricuspid bruit. 

1. Girl, aged 8. Mother has had rheumatics bat nothiug of 
importance. Patient has never had rheumatism. Always 
ailing. Systolic hmit over third left costal cartilage and 
sternum at same level. Second sound very accentuated. 
Impulse felt far into the axilla in third, fourth, and fiflh spaces. 
A systolic bruit heard inside the nipple. Five months later the 
bruit remained the same. She came complaining of bruising 
so readily and with several bruises on the shins and knees, 

I. Girl, aged 6. Father has had lumbago badly. A cloud of 
albnmen in the urine. Much pallor. An apex Bystolic broit- 
Three months later the impulse of heart forcible j no bruit. 
Urine normal. Four months later she was quite well. 

B.. Boy, aged 16. No family history of rheumatism. Has 
had rheumatic fever three times. Heart's impulse diffused in 
fourth and fifth spaces from inaide to outside the nipple ; 
double second sound at the apex ; alight systolic bruit ; 
systolic retraction in fourth space. 

G-. Boy, aged 10. Mother has had rheumatic fever, ill for six 
weeks. Impulse of heart forcible and difi^ised ; systolic retrac- 
tion below the apex ; no bruit. 

B. Boy, aged 12. No rheumatic fomily history. Had rheu- 
matic fever five years ago, and since then has been subject to 
rheumatism. Diffused impulse outside the nipple in the fifth 
space. A loud systolic bruit at apex audible at the back, with 
thick double secood sound at the apex, accentuated at the base. 

G. Boy, aged 16. Mother died of heart disease. He haa had 
rheumatic fever in Guy's. Impulse forcible in fifth space ver- 
tically below the nipple. Fnecordial dulness increased. First 
sound thick with an occasional bruit. Enlarged heart. 
Adherent pericardium. Thickened valves without much in- 
competence. 

G. Girl, aged 8. Father lias been laid up with " rheumatics " 
and mother has had it in her knees, being laid up eight i 



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On the Rheumatic Diathesis in Childhood. 120 

and twelve weeks respectively. Friecorclia bulging. Heart's 
impalae diffnted far outside tbe nipple. Loud systolic bruit all 
over tiroDt and back of chest. 

R. Girl, aged 13. Family history not recorded. She has 
bad rhenmatic fever, and has now advanced mitral disease. 

G, Boy, aged 10. Mother has had rheumatic fever. Ailing 
for two months after a fright. Pallor. Fnecordia bulging. 
Impalse diffused. Diastolic thrill. Distinct whiEBng systolic 
brnit midway between nipple and ensiform cartilage. Much 
accentuated second sound at base. 

G. Girl, aged 16. Mother had rheumatic fever. A few 
weeks back she had swelling of knees and wrist. Heart's 
action diffused. Slight systolic thrill. Loud systolic bruit all 
round the nipple, in axilla and back. Twelve months later 
this note is made : — Impulse diffused in fifth space far into the 
Biilla. Heart's action cantering, with occasional systolic bruit. 
Thick sounds in axilla. The sounds give one the impression 
that tbe mitral valve is thick and narrow, but only moderately 
so. Tbe mitral lias probably contracted between the two 
attendances. 

6. Boy, aged 15. Mother died of heart disease. She had 
rheumatic fever four or five times. Has bad heart disease 
four years, and been id other hospitals. Frsecordia bulging. 
Much increase of dulness. A loud systolic bruit all over the 
pr^ordia. Heart evidently much enlarged. 

6. Boy, aged 13. Two brothers and two sisters have been 
under me for heart disease or rheumatism. Maternal grand- 
mother suffered from rheumatic gout. Has bad rheumatic 
fever twice. Heart's action heaving. Impulse in fifth inter- 
space inside nipple. Loud systolic apex bruit; somewhat 
Iocs] in its point of greatest intensity ; not heard in the back. 

G. Boy, aged 10. Same family as previous case. Said to 
Mie bad rheumatic fever after scarlatina. Impulse external 
^iiipiile. Loud regurgitant mitral bruit, heard all over back 
wicl front. 

6. Girl, aged 8. Same family as the two preceding cases. 
KbeDmatism four years ago, and since then three other attacks. 
neart g impulse in the sixth space, in and outside the nipple 
"*■ Systolic apex bruit, with double second eonud, heard 
'">'» sternum to nipple and into the back. 

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180 On the Rheumatic Diathesis in Childhood. 

6. Girl, aged 7. Same family as the previous three cases. 
Has had rheamatism (?) after Bcarlatina. Heart's actioa irre- 
gular ; first soQDd rough, second persistently acceutoated and 
sometimeB double. No thrill, but impulse is over forcible. 

G. Boy, aged 4. Same family as preceding four cases. Has 
had rheumatics all the winter; not kept his bed, bat has been 
dressed and put in a chair. The heart is normal. 

G. Boy, aged 6. Mother has had rheomatic fever. Heart, 
thick first sound at apex. 

I. Girl, aged 6. Paternal grandmother suffered mach from 
rheumatics. Heart's actioa cantering; sounds muffled; action 
rapid; apex diffused; short, rough, diastolic bruit. Svelling 
of knees and feet now present. 

I. Boy, aged 8. Father has rheumatics in back and ankles. 
Came first with loud systolic apex bruit, and subsequently 
developed a pericardial rub. 

I. Girl, aged 9. Maternal grandfather rheumatic. Has 
pains. Heart's impulse thumping and diffused outside the 
nipple. Slight systolic bruit in fourth space, midway between 
the nipple and steraum. 

G. Boy, aged 6. Father boa had rheumatic fever twice. He 
has had rheumatic pains about him. Heart's impulse diffused 
in fifth space outside the nipple. First sound thick, and an 
occaaional short whiff. 

M. Girl, aged 11. Father and paternal uncle suffer much 
from rheumatic gout. Mother has fits. Heart's impulse 
forcible. First sound thick and long. 

Q. Girl, aged 6. Father has had rheumatism and was laid np 
for some months. A loud systolic bruit at apex. Impulse 
forcible below and external to nipple. 

|. Girl, aged 12. Rheumatic family history probable. Heart's 
impulse forcible in fifth space. External to nipple, first sound 
peculiarly loud and high pitched, followed by a hoarae systolic 
bruit, loud in axilla and back. 

1. Girl, aged 7. Father subject to rheumatism, never laid up. 
Ailing since the scarlatina, six months ago. Heart's impulse 
diffused in and outside nipple; loud systolic bruit all over 
heart's area, with accentuated second sound. Bruit very loud 
in the back. 

G. Gill, aged 17. Maternal grandfather had rheumatic fever 

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On the Rheumatic Diathesis in Childhood. 181 

badly three times. Mother has rheamatism occaBionally. 
Girl had rheumatic fever four years ago. Heart's impulse 
forcible and diffused j loud systolic apex bruit audible iu the 
back. 

6. Girl, aged 9. Brother had rheumatic fever. Marked 
anemia. Impulse forcible, external to nipple. First Boand thick 
and distant, second accentuated at base ; no bruit. 

G. Girl, aged 7. Mother has had rheumatic fever. Child 
had "growing pains." Heart impulse very forcible in fifth 
space, half inch external to nipple. Slight musical systolic 
bruit round apex. Doubtful in the back. 

M. Girl, aged 5. Paternal grandfather has rheumatic gout. 
Heart impulse diffused outside nipple. First sound thick and 
musical, second occasionally double at the apex. 

M. Girl, aged 5|. Mother had rheumatics, but never laid up 
with it. Child has frequently cried with pains in her limbs. 
Heart's action very rapid and cantering. Systolic thrill; 
diffused impulse ; apex far outside nipple ; loud systolic bruit. 

E. Girl, aged 9. Family history not stated. Has had rheu- 
matic fever. Long and loud systolic bruit at the apex. The 
bruit is a little musical, and preceded by a very noisy first sound. 
Impulse in sixth space, one and a half inches external to the 
nipple; systolic thrill ; broit load at the angle of scapula. 

R. Girl, aged 7. Has had rheumatic fever three times. 
Family history omitted. Loud systolic bruit with very loud 
ringing first sound ; impulse iu fifth space vertically below the 
jiipple. 

G. Girl, aged 11. Father has had rheumatic fever. Heart's 
action tumultuous and irregular; no bruit; impulse forcible. 

G. Oirl, aged 9. Brother under my care for scarlatinal rheu- 
matism. This child under me four years ago for "heart 
disease." Notes of case lost. Impulse now diffused in fifth 
space inside the nipple, and the first sound is thick with a 
little reduplication of second sound. Nothing else to be noted. 

G. Boy, aged 8. Father had rheumatic fever four times. 
This boy had it when five. Frequent palpitations. Heart's 
action forcible in fifth space. Action regular. Sounds very 
thick and distant. (P) Adherent pericardium. 

O. Girl. Mother has had rheumatic fever. Child has bad it 
before. Loud mitral bruit with extensive pericarditis. 



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132 On the Rheumatic Diathesis in Childhood. 

G. Girl] aged 9. Sister died of heart diaeaae. Heart's actioa 
quick and forcible !n fifth space beneath the nipple. 

Q. Girl, aged 7. Mother bas had acute rheumatism twice. 
One brother has also bad it while under my care. Hearfi 
impulse forcible. A loud hoarse bruit consisting of systolic 
and pnesystolic portions. Heard loudly in axilla and back. 
Slight thrill at apex. 

R. Girl, aged 1I|. No family history of rheumatism to be 
obtained. She has bad rheumatic fever. Loud apex systolic 
bruit heard in axilla and back. 

G. Girl, aged 11. A brother or sister died of heart disease. 
No other evidence of rheumatic taint. Heart's action irregular. 
Impulse in normal position but forcible and grating. No dis. 
tinct bruit. 

B. Girl, aged 10. No family history of rheumatism. Had 
rhenmatic fever once for fire weeks. Brheumatism frequently. 
Heart's impulse forcible^ far esteraal to nipple. Slight thrill. 
Loud systolic musical bruit back and front. 

G. Girl, aged 4}. Father had rheumatic fever eleven years 
ago. She has had it. Advanced mitral disease with acute peri- 
carditis and dilatation. 

B. Girl, aged 6. No rheumatic history in family. Her 
brother aged eleven months was brought with a curious neuro- 
muscular fault in the action of fauces and oesophagus. She has 
had rheumatic fever. Diffused impulse, no bruit. 

M. Girl, aged 12. Maternal grandmother bad rhenmatics 
badly, and rheumatic fever. This child has had paina in he^ 
bones and chorea. Heart's impulse far outside the nipple. 
Slight thrill. Systolic apex bruit. 

M. Boy, aged 8. Family history of heart disease. None of 
rheumatism. Systolic apex bruit. 

B. Girl, aged 6. Family history not mentioned. Has had 
rheumatic fever and chorea, also pericarditis. Loud systolic 
bruit at the apex and in back. 

G. Boy, aged 5. Father has had rheumatic fever three times. 
The child not known to have bad it. Systolic bruit at the apex. 

G. Girl, aged 8. Sister died in hospital with heart disease. 
Extensive precordial dulness, and diffused impulse. Very thick 
and accentuated second sound. (?) Adherent pericardium with 
thick valves. 

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On the Rheumatic Diatkeiia in Childhood, IS8 

&. Boy, aged 6. No rheumatic family history. He has had 
<t> Loud mitral bruit with ascites aud anasarca. He was 
relieTcd by paraceutesis, &c., and still goes along pretty well 
three years after. 

I. Boy, aged 4. Rheumatism for four mouths. Pallor. 
Loud, long systolic bruit round the impulse. Father has 
ihEumatic pains but baa never been laid up with the fever. 
Mother healthy. Patient haa not had chorea. 

M. Girl, aged 6. Double murmur at apex. Systolic at 
back. Impulse vertically below the nipple. Maternal aunt 
hu had rheumatic fever. Mother has bad rheumatism, but 
vu nerer laid up nith it. Father has also had it, especially 
iQ changing weather, but is not laid up with it. 

0. Boy, aged 14. Brother had rheumatic fever. Patient 
had rheumatism for three months four years ago. Heart's 
impnlie in fifth space inside the nipple. Systolic bruit fol- 
loinng a thick first sound. 

R. Boy, aged 11^. Family history unknown. Rheumatism 
sttd Bvelling of joints three weeks. Heart's action quick ; 
impalie diffused and external to the nipple. First sound soft 
asd thick. 

K. Girl, aged 10. One other child suffers from headache. 
Sheumatic fever two years ago. Loud mitral systolic bruit ; a 
Kcond systolic bruit of musical quality at ensiform cartilage ; 
(?) tricuspid. 

B. Girl, i^ed 16. BJieamatic fever four years ago. Impulse 
iti'nitb apace beneath the nipple. To and fro aortic brnit, and 
>t apex the first sound is long, loud and muffled, with much 
the character found in some cases of contracted mitral. 

G. Girl, aged 16. Mother has had rheumatic fever. Patient 
l)u had two attacks of rheumatism. There is a long thrill, 
chiefly diastolic, but also systolic. Impulse forcible in fifth 
■pace half an inch external to the nipple. Bruit a typical pne- 
'ftolic followed by a diastolic roll. 

. ^- Girl, aged 10. History of rheumatism doubtful on father's 
'"'*■ She has frequently been laid up by aching in her limbs. 
^7 forcible thrilling impulse diffused in the fifth space 
**lemai to nipple ; first sound very noisy, and very short, dis. 
*"" systolic bruit following it. 
^- Girl, aged 14. Mother has had rheumatic fever. Child 

. „ Google 



134 On ike Rheumatic Diathesis in Childhood. 

has flnid in one knee and enlargement of both wrists. Heart's 
action rapid ; first sound thick, and distant whiffing prolongation 
of first Boand in the left vertebral groove. 



8. Chorza. 

R. Girl, aged 9. Family history &ee from rheumatism. She 
has had rheumatic fever. Heart normal. 

G. Girl, aged 6. Paternal aunt had rheumatism at twenty- 
eight. Mother has had rheumatic fever, and maternal aunt had 
rheumatic fever several times. Heart, mitral systolic; (?) 
preesystolic, 

N. Girl, aged IS. No history of rheumatism. Systolic apex 
bruit. 

G. Girl, aged 4}. Father baa had rheumatic fever. Patient 
has frequently sufi'ered with pains in her limbs. Heart normal. 

N. Girl, aged 9. No known history of rheumatism. 

N. Girl, aged 10. No known history of rheumatism. Heart 
normal. 

R, Girl, aged 10. No family history of rheumatism. She 
had rheumatic fever two months before. Heart normal. 

G. Girl, aged 19. Father has had rheumatic fever and patient 
also. Systolic mitral and diastolic aortic bruit. 

G. Girl, aged 9. Father has been laid up with rbeumatism. 
Heart normal. 

N. Girl, aged 10. No rheumatic history. Heart normal. 

N. Girl, aged 10. No rheumatic history. Apex systolic brait, 

N. Girl, aged 9^. No rheumatic history. Heart normal. 

M. Girl, aged 7. Maternal grandfather has been laid ap with 
rbenmatism. Maternal auut and uncle have had rheumatism. 
Heart normal. 

I. Boy, aged 10. Father has had " rheumatism." Two other 
children have had chorea. Heart normal. 

G. Girl, aged 12. Rheumatic family history. Chorea after 
joint pains. Systolic apex bruit and thrill. 

N. Girl, aged 7. No family history of rheumatism. Second 
attack of chorea. Heart, loud systolic bruit and pericardial rub. 

G. Girl, aged 11. Father has had rheumatic fever. Mother 
has had chorea. It is the fourth attack. Heart normal. 

Googk 



0» the Rheumaiie IHatheBtt in Childhood. 185 

N. Oirlj aged 8. No faistoiy of rheamatiBm. S^atolic apex 
bniit. 

Af> Girl, aged 10. Rheamatic histoiy on father's side. 
Heart nonnal. 

N. Boy, aged 10. No rhenmatic hutory. Alwaya nemnu. 
Heart normal. 

B. Girl, aged 10. No family history. Rheumatic fever five 
months ago. Mitral systolic bruit. 

O. Boy, aged 18. Mother has had rheumatic fever, so also 
haa boy. Heart normal. 
N. Boy, aged 9. No rheamatio history. Heart aonual. 
R. Girl, aged 16. Rheamatic f^er one year ago. Mitral 
■ystolic bruit. 

G. Boy, i^^ 8. Father haa had rheumstism in several 
joints, so also haa boy. Heart, no bmit. 

N. Oirl, aged 18. No rheumatic history. Thick first sonnd 
u>d occasional systolic bmit. 

— ■ Girl, aged 12. Family history not stated. First sound 
thick. 

^ Boy, aged 10. Has had rhenmatic fever four years ago. 
I^k first sonnd, and occasional short rough bruit. 

^' Oicl, aged 12. Mother has had rhenmatic fever, and child 
■•m- Chorea attributed to a fright. Short systolic bmit at 
bate. 

0. Boy, aged 9. Mother had rheumatic fever, and died of 
•wwt diieaae. Systolic basic bruit. 

^- CFir], aged 16. Father laid up for long in bed vith rben- 
°»|Mm. Heart normal. 
*'■ Girl, aged 8. Mother had rheumatic fever and child also. 
™rt iajge ; systolic apex bmit. 
p ' ^^1, aged 14. Mother has had rheumatism in the shoulder, 
p"* had fits. First sound thick. 
, * ^*i«"l, aged 16. Mother has had rheumatism. Third attack 

gj^l/^*l, aged 18. Mother has bad rheumatism slightly3 

jj *' of fright. First sound thick and musical, 
Hg-A_ ^irl, aged 4^. Paternal grandfather Lad rheumatic fever. 



*^onnal. 



*ie*rt 

'^Otov,^^'' *8«^ ^1- Father has been laid up in bed with 
^°**tiBin. Heart normal. 

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136 Or the Rheumatic DiathetU in Childhood. 

R. Girlj aged 14J. Fains ia joinU three weeks before chorea. 
Indistinct history of fright. Systolic apex bruit. 

G. Girl, aged 10. Mother has had rheumatic fever. Heart 
normal. 

G. Boy, aged 13. Mother and one of his brothers have had 
rheumatic fever. Heart normal. 

G. Boy, aged 8. Father died of diseased heart. Chorea three 
months. Loud systolic apex bruit. 

G. Girl, aged 5. Father has had rheumatic fever. Chorea 
after fright. Heart sounds coarse. 

G. Boy, aged 11. Mother has articular rheumatism. ~No 
heart disease. 

M. Boy, aged 10. Paternal grandfather and aunt have had 
rheumatism. Second attack. Heart normal. 

N. Boy, aged 15. No rhenmatic|^history. First sound thick, 
impulse diffused. 

R. Boy, aged 5}. Rheumatic fever foUoTred by chorea after 
a month. Loud apex systolic bruit. 

R. Girl, aged 5^. No rheumatic family history. Has had 
pains in her limbs. Loud apex bruit. 

R. Girlj aged 8. Chorea after painsia her joints. Nofamily 
history. Heart normal. 

— . Girl, aged 7. Slight chorea. Heart normal. Family 
history not noted. 

G. Boy, aged 9. Mother has had rheumatic fever. Heart 
normal. 

N. Boy, aged 4. Mother epileptic. Heart normal. 

N. Girl, aged 5. No rheumatism. Heart normal. 

M. Girl, aged 4^. Paternal grandfather had rheumatic fever. 
Heart normal. 

N. Boy, aged 5^. No rheumatic history. Heart normal. 

I. Boy, aged 4. Sister had chorea, under my care. Heart 
normal. 

G. Girl, aged 6|. Maternal grandmother had rheumatic 
fever, and aunt heart disease. Has had fits. Heart normal, 

G. Boy, aged 11, Father had rheumatic fever. Heart 
normal, 

I. Girl, aged 5. Father rheumatic. Heart normal, 

N. Girl, aged 4. No family history. Heart thumping, with 
apex bruit. 



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On the Rheumatic DiaihaU in Childhood, 137 

— . Bof, aged 5. Family history not mentioued. Pint 
sound long. 

G. Girl, aged II. Both father and mother have had rhea- 
matic fever. Systolic apex bruit. 

N, Girl, aged II. No rheumatic history. Secood attack of 
chorea. Previous attack two years before. Load systolic and 
pnesTstolic bmits, 

I. Boy, aged 11. Father has had rheumatics. Heart 
nonnal. 

I. Girl, aged 10. Father's family rheumatic. Third attack 
of chorea. Heart normal. 

G. Girl, aged 7. Paternal uncle rheumatic. One brother 
of this child had rheumatic fever and died of heart disease. A 
sister Has had chorea. Heart normal. 

— ■ Boy, aged 9. Family history not stated. Heart normal. 

Q. Girl, aged 7. Father had rheamatic fever. Heart 
nonnaL 

G. Boy, aged 10. Parents healthy. One brother has had 
rbeomatic fever. Heart normal, 

N, Girl, aged 6. Parents healthy. Heart nonnal. 

N. Boy, aged 8. No rheumatic history. Heart normal. 

L Girl, aged 8, Parents healthy. First cousin, mother's 
Bule, had chorea and has heart disease. Heart normal. 

0. Girl, aged 8}. Brother has had rheumatic fever, and so 
has she, chorea since. Heart normal, 

N. Girl, aged 6. No family history. Heart normal. 

G. Girl, aged 9. Mother has had rheumatism, and in bed a 
month. Chorea attributed to fright the night before its onset. 
Heart normal. 

Gout Girl, aged 11. Father has had gout for some years. 

Qout, (?) Girl, aged 9. Has had erythema nodosum after scar- 
Utina. Paternal grandfather had gout badly, and died of dia- 
eued heart. 

0, Giri, aged 8, Mother has had rheumatic fever. Heart 
sormsL 

G. Girl, aged 6. Father has been laid up a month with 
rheamatics. Mother also has kept her bed with rheumatic 
gout Heart normal. 

H. Girl, aged 9. Fatenia) annt baa had rhenmatic fever. 



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188 On the JtAeumatic Diathetu in Childhood. 

She has had aching* in her limbs. Fnesystolic apex brait, with 
slight thrill. 

M. B07, aged 10. Grandmother had rheumatic ferer. Child 
had rhenmatic fever after scarlatina foor years ago. Syitolic 
apex bmit. 

N. Qirl, aged 7. No rheumatic history. Heart normal. 



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ALOPECIA AREATA. 



Bt p. K. PTE-SMITH, MJ). 



Wi may, perhapa, distingniah the following kindB of alo- 
pcria. 

1. The physiological fall of hair vhich produces ordinary 
c&lvities is characterised hy its comparative rarity among 
Tomen, by its alvaya beginning at the vertex or in the frontal 
region, by its spreading gradnally and not by patches, by 
its never reaching the temples and very seldom the occiput, 
and, lastly, by its affecting the scalp alone. Though often 
accompanied by seborrhoea sicca, and less frequeotly by tree 
pttTriasie capitis (a branny desquamation indicatire of a slight 
degree of superficial dermatitis), baldness also occuri without 
these affections, which I regard rather as concomitants than aa 
causes. Nor is it true, as has often been asserted, that bald- 
ness depends on loss of mobility of the akin by the occipito> 
Entails. 

2. Alopecia aa the resalt of febrile and other general dis- 
eases, though it often begins the process of ordinary baldness, 
yet is distinguished therefrom by its affecting both sexes and 
all ages, by the fall of hair not being confined to any region of 
the scalp, and by its thinning rather than completely stripping 
the surface affected. Moreorer, secondary in origin, it also 
puses away of itself after conTalescence, instead of being prac- 
tically incurable either by nature or by art. Syphilitic bald- 
ness agrees in these characters, and its frequency apart from 
any other affection of the scalp, as well as its early appearance, 
likewise point to its setiology as a febrile alopecia. 

3. There are some cases of complete and rapid loss of hair 
which do not come under either of the above heads, and 

. „Gooj^lf 



140 Alopecia areata. 

which yet, I believe, cannot be claaaed as examples of area. 
They are diBtingniBhedj first, by the hair falling off almost 
Bimultaneonaly from the whole of the scalp, not gradually from 
certain regions as in ordinary baldness, nor by the confluence of 
separate patches as in area; secondly, by the baldness not 
being confined to the scalp (nor even to the scalp and beard or 
eyebrows as I have seen it in area], but affecting the whole of 
the body: thirdly, by its not following an iUuess. In one 
case of this kind the patient was a young man in perfect 
health, of robust habit, and wearing a full beard. 'Without 
any assignable cause he lost the whole of the bair of his body 
in a very short space of time. I know of two or three other cases, 
also in yonng and healthy men ; and, comparing these with 
the most rapidly spreading cases of alopecia areata, I think they 
may be fairly distinguished as a separate form of baldness. 

4. It is questionable whether these somewhat rare cases of 
alopecia universalis acquisita are pathologically to be distin- 
guishable from the still rarer cases of congenital alopecia. In 
these the nails as well as the hair are affected; and, like 
other deficiences of development, the condition may be heredi> 
tary. Such cases are comparable with congenital ichthyosis, 
especially in such marked examples as the " porcupine boy;" 
and still more closely with the " hairy family" of Burma, and 
the blue or hairless horse exhibited a few years ago in this 
country. 

A striking series of examples of this form of baldness 
occurred five years ago in this hospital under Dr. Fagge^ who 
kindly allows me to record it here. It is remarkable that the 
development both of hair and nails was tardy and imperfect, 
but not absolutely deficient. 

F.i Born without hair or nails. Hair began to grow when 
he was about twenty-three years of age, and at thirty he had a 
full head of hair. The finger-nails also grew after puberty, but 
were always ill-formed, and he never had toe-nails. 

' The notatiOR U thkt of Mr. Fnnci* 0>ItaD in hit inUreitiiig work on 
■ Hereditary Oenini.' Y, O, B, 8, F dsnoto fktber, grandbther, brothar, md, 
and grandion rapectivelj, and the Mme letten in itilie th* eorratpoodin; 
female relationihlpa of motiMT, grandmother, *iit«r, danghter, and grand- 
daaghtcr. N ii a hrother'i wii, n a liiter*! wm ; U a father'i brother, n i 
mothar'a brother ; and, by tUo above rule, A' a briitl'Cr'i, and n- a aiBtcr'i dapsh- 
tcr; (rahtlier'a,Rnd«*inotber'a«iil«r. 



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Alopecia areata. 141 

F. Norm&l. 

B 1. Bom without nails or hair. The foimer appeared while 
teething;, the latter when she was tea years old. 

n. Bora withont hair and iiails. None yet grown, 

B2. Born with hair but without nails. Died xt. seTen. 

B 3. Bom withont hair or nails. Died tet. five months. 

B B 4—9. Bom with normal hair and nails. 

BIO. Bom partly bald with ill-formed nails. Was under 
Dr. Owen Reea when a boy. He is now twenty-two and has 
a fair head of hair, but his nails are not good. 

The patient herself, then nineteen years old, the elerenth 
uid youngest of this lai^ family, was bom withont hair or nails. 
She had in 1876 only thin lanugo orer the scalp, and imper- 
fect nails on fingers and toes. 

5. There are then clear marks of distinction between these 
lereral forms of alopecia, idiopathic and secondary, and the 
remarkable affection known as Altgiecia areata (Sauvages), 
Area Celti, Porrigo deealvana (Willan), Teigne pelade (Bazin), 
or Tifua decalvatu. Indeed, so peculiar is the appearaoce of 
this disease, that what is more aeedCuI to insist upon ia that in 
spite of its well-marked characters it is a tme alopecia, ana- 
tomically identical with the other forms of atrophy of the hair, 
though differing in its origin and course. 

The first of the above titles appears to be best, since it is 
distingoisbing and is generally accepted j or the term area 
may be used alone. Celsus did not particularly describe this 
variety of baldness, but applied the word " area " (a bare space, 
loaa Hne adifieio) to any form of baldness, distinguishing 
aA»nn|K/a and i^iaai^ as varieties.' The Porrigo of Willan 

' Se« Batcman'i 'Praetic&l SyDopiii' (1924), p. 175, note, ud Hebn'« 
' UtntkrukhciUni' p- 14B. NeitlieT of theie lathon nobicM that vague ■■ wu 
Celioi'i nie of bobh terms, area and aUipeaiii, (nbieqaent nriUri used them ttill 
more Taguelj. Thua, Stephanaa in hia 'Vocsbalonun HcJicinaliuin Eipo- 
titioDe* Graecao' (lEr64), p. 204, quotea IVom Lhe Qalenlcal 'Defenjio Medicinra,' 
'IXMrqvia tl iari fiEro^Xij rou j^pw/iaroc jirl XivKoTipov, ti' ^v xpof f^ovvav ol 
rplx't piIoOiv iirowijrTovttiv. He aUo g'ives tbe following iccimnt from 
OribaiiDi of tlie cause of the moladj ; — " Alopaeia vara inde «(hm» invenil quod 
vdptt, qtM rUwrqE iicUttr, Jmb malo lapt corripialar. Oritur aiiltm pit. 
riimqiu ex tUtont kumoriitu eapila conUntU, *ei malUia ipechm ipte capitii 
color indicat : 9«tp}» aiiWior pUtUlotWH, nigrior matanehoUevm hvmortm. 



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142 Ahpeeia areata. 

meant any ernption of the scalp, including true ringworm and 
impetigo or pnatalar dermtLtitie, and theterm is now almost 
out of use. The appellation Tinea or Teigne depends upon 
the erroneous doctrine of the parasitic nature of the disease. 

On this point I am entirely in accord with most modem 
dermatologists, I have many times sought for a fasgus, and 
have never found the smallest evidence of its presence with 
one single exception. This occurred nearly fifteen years ago 
when I was working under the late Professor Hebra. Id one 
of bis patients suffering from area I discovered some spores 
and scanty mycelium close to one of the neighbouring faairs. 1 
■bowed it to the professor, and he told me that he had never seen 
it before. He doubted whether its occurrence was more than 
accidental, and with my present experience I doubt it also, 
Hebra himself believed at one time in the statement of Gruby 
that the disease was parasitic, but bad long changed bis opinion ; 
and I can only share in the surprise expressed by Dr. Kaposi 
(Hebra's ' Hautkrankheiten,' ii, p. 149, note) that the author 
is associated with Bazin as a supporter of the parasitic nature 
of area by his disciple Dr. Neumann (' Lehrbuch der Haut- 
krankheiten,' p, 297). It is possible that the single observation 
of Gruby ^ in 1843 which gave rise to the question was made 
upon a case of true ringworm. Keumann, who has no doubt 
that area is not parasitic, once, like myself, found some spores 
in a case of the disease, but, like myself, doubts rather the 
accuracy of a single observation than the accumulated testi- 
mony of his own and other's experience. In fact, M. Bazin's 
statements are, I believe, the only ones which rest on large 
experience and assert the presence of a fiingus. Bat French 
dermatologists call many cases pelade or teigne pelade which in 
England or Germany would be regarded as true ringworm in 
its later stages. In M. Hardy's brilliant lecture, it is not 

pallidhr flavam biUm argM.'' The orlgia of the term receive! two kltematiTe 
expluution* In BUncard'i ' Lexicon MediciuD,' pnbluhed tX Lejden id 1703. 
" Atopaeia a*t eapiUonm dijbaium, a Im vensraa val aliu^dt meitaium, nr 
4\wimE DNfpM >( irlwru eado (!) .■ a eulpe rt(;iu ludim effkta dicilur nddtre 
loea . . . vtl a malo talpi peanUari. Voeatur atiam 6fiaatt afytra . . 
Viriqut huie afftetai eammune att, quod arealim pili dtcidnmi, *»d4 ttiam 
in y»Mra koa malum Axea vocatur." 

:t wu pnbliihed by Andouiu, ftfter whom the guppoaed fnngoi wu Duned 



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Alopecia areata. 143 

difficalt to recognise in the sirelling, irritation, and diBcolora- 
tion of the akin which he describes in pelade,'^ the characters 
of ringworm. I never saw at the Hospital of St. Louis an 
attempt to demonstrate the presence of spores in what we 
Bhoold call a case of area. 

Apart from the microscopic evidence, the ni^ed-eye appear- 
ances and natural history of the disease woold alone dtsproTC 
the parasitic hypothesis. The hairs around the affected spot 
ate not swollen at the root nor brittle in the shaft, but are 
simply atrophied, like Donnal hairs which are ready to drop off. 
There is no evidence of local irritation in the hair-sac. The 
disease above all is not contagious, at least as we observe it in 
En^and ; and it is not curable by antiparasitic treatment.' 

Area is certainly more common in children and young adults 
than after thirty. It seems to affect both sexes equally. In 
most cases it probably would recorer of itself, but I believe 
that recovery is often hastened, if not brought about, by treat- 
ment. Tbia consists (after establishing the diagnosis) ia local 
irritants, and, when necessary, internal corroborants. I usually 
b^in with a lotion containing ^iss or ^ij of Acetum cantharidis 
to a pint of water. This will often cause slight erythema in 
children, but in adults and in many children we may increase the 
strength to two, three, or four drachms with advantage, letting 
the inritatiou subside whenever it goes beyond redness on 
to exudation. A milder and often efficient application is Znni- 
mentnm myristics, which I learnt &om Sir Wm. Gull when he 
had charge of this department. With brown hair the Un- 
goentum iodi of the Pharmacopoeia is a very usefiil applica- 
tion. Area occurs in persons ofall degrees of health, complexion, 
and " temperament," but if the patient is pale and thin, steel is 
certainly useful, and I often prescribe bark or cod-liver oil, but 
only when indicated by some other symptom than the bald 
patches. 

I have only seen one instance of a second attack of area 

' ' LoQoni rar 1m Hmlmdica de !■ Fmo/ 2du putie, pp. 179 — IM. 

* The following list pitm th* nuiM of the matt imporUnt anthorWe* on 
both udo of tbii qoeetion. In fsTonr of the panutic oiigin of uet i — Qrahj, 
Butn, Hardf, and French writen ^nenll; (except CkHnave, who confounded 
tnt. vitli ntiligo), the Ute Dn. EiUier uid nlbnry Fas (the Utter ednitUng it 
only In > verj iDuUl proportion of cues). Againit thi> opinion :— BKniiupnmg, 
UatcB, WUun, Hntebinion, FaggOi Uveln^ , Dahring, uid Alder Dniith. 



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m 



Alopecia areata. 



appearing after a first bad been completely cured auA an 
iateiral of time had elapsed. 

The following is a list of the cases of alopecia areata trhich 
have come under notice in this department during the years 
1878, 1879, 1880. 



Kg. Iso. 


ip 


=„.„»,w 


Pnuutdlcat. 


Houika. 


1 


F. 


20 


Be^Q at 4 or S. 


Complata otbt Kalp. ex- 


KegaUve reinlt after 6 








Complete afUr 


cept ilight Unugo here 










mcwlw Bt 11, 


and there 










but ajabrows 
























h«TB grown 






2 


F. 


18 


Siva's jemoU 


browi 


Treatment not aU 
tempted. 


3- 


M. 


17 


Besim It 14 


'^L^'^^ZZ-'" 


Brother of No. 2. 


4 


P. 


26 




P»tche« on (olp. 




6 


M. 


16 




Do. 




6 


K. 


40 




Do. 




7 


P. 


10 


— 


Nearlj complete orcr 
■cftlp. 
Scalp and beard. 




8 


M. 


23 


_ 




9 |M. 


25 


About a j«ir 


Patcbea on ualp. 




10 , M. 


24 


Two month* 


One patch behind ear. 
Nearlj complete on icalp 




11 P. 


17 






12 M. 


14 


Sii monthi. 






IS M. 


16 


Nine montbi 


I^t«hea on aealp. 




U M. 


12 


Four ymra 


Nearl; compUU on (calp 


Dark and pale. 


15 


M. 


19 


Five moDtlii 


Patcbe> on scalp, Kveral 
along middle line, thf 
rert UQiym metrical 


Brown Imir. Thin, 
healthy. 


16 


M. 


boj 


Two uoDtha 


Three patchea oo icnlp. 


Brown hair. Ilcnlthv. 
Recovery after flv. 
montba' treatmeist bj 
Ac. Cnuth. 


17 


P. 


8 




Patchet on acalp 


Alao ordinary impetipi 
of face and acalp. 


18 


M. 


26 


Eight month* 


Scalp and mouttacbc 
Pnbea. Ik., imaffected 


Strong bcalth7 man, 
darkTiair. 


19 


H. 


8 


rwelro months 


Two patchei on occlpnt. 
Three eoale>c«d patc^ea. 




20 


P. 


6 


riiree monthi 




21 


H. 


21 


rbr«« moDtb* 


Five patchei on acalp. 




82 


P. 


22' 


~ 


Patchei on acalp 


Left arm and leg waited 

from infantUe laliiv. 


23 


M. 


12 


Pour yfttw 


Confineot patcbea OTer Dark hair. It«meor 
nearif the whole icalp.l after chorea " from a 

ti*m; no bruit. 

1 


" 


IWi 


joqn, 


g wonuui mii tb 


at aercD year* ago aha had 


the aame bald patekea 



D„tM,Google 



Alopecia areata. 



Sa. ^.lOantioBirf 



u 


M.I 


a 


P.' 


K 


V 


■a 


M.' 


M 


S,' 


^ 


K 


;fo 


M 




¥ 


Hi; 


M 


Si 


F. 



11 A few montlu Almost the whole of the A well-ourked patch of 
p I tinea dKinata o 

Exteniive baldnew of HntUby. light hair, 
•est p. Eyebrowi amll 
ejelashea iJk) going 
Pstche* on icalp | 

Patchea on acalp (hair 
light) I 

I^tcliei on scalp (hair Cared with Ac. Canth, 
dark, almoat black) Hair flnt white. 

f^^Teral montha Eitenaive OTcr icalp j Light hrown hair. 

P.ve mnDtha TfameronipBtcheaonacalii 
Sii months Severa) patches on scalp ! b'ur. 

ISecondtime Three patchu ~ ...-. — . 

montha iThree patches 



PoarteenmoDtba Two patehei 

Poor months Nenrlj the whole scalp 
Three mantbs , Several lai^ patches 
-'"- -reeks One patch on occiput 



Dirk hair. Well ddu- 
riihed. 
Fair bair. Healthy. 

Dark. Thin. Healthy. 



vn the head, and attended for two jeara at Guy's Hospital, at the end of which 
time the was cured. 

' This boy's hair is said to hare fiklten oV last anmmer and to hare grown 
•jsin. 

' A liiter is s^d to bare lost her hair itt the same way and to hare reco- 



■ These t»o noD (Ng*. 27 & 21 



« between SO and 80 yean ol 



.y Google 



D„t,M,Google 



ON THE 

IlTAIi TERMINATION OF DIABETES, 



ESPECIAL EEFEEENCE TO THE DEATH BT GOUA. 



Bx FEEDEEICK TAYLOR, M.D. 



WiTBiN the lart few years considerable iDterest has been 
excited in the fatal termination of diabetea by coma, and 
various attempts have been made to explain its occurrence by 
refercDce to alterations in the chemical or physical properties 
of the blood. I have bad the opportunity of ffatching several 
such cases in the wards of Guy's Hospital, and I have collected 
the notes of them in the hope that tbey might form a eontri- 
batioD of more or less value to the subject, at least from a 
clinical and etiological point of view. I was also partly led to 
do this from the impression I formed that cases of death by 
coma were really very much more frequeat than writers on the 
subject had formerly represented them to be; and I was 
further anxious to ascertain if the cases which did not die of 
auch complications as phthisis, pneumonia, and gangrene and 
of intercurrent diseases, terminated in one and the same 
manner, or how often death occurred from simple exhaustion 

OT uy form of blood-poisoning apart from the death usually 

Aewribed as by coma. 

During the last eight years, from 1873 to 1880 inclusive, 

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On the Fatal Termination of Diabetes, 



148 

43 deaths have occurred &t Guj's Hospital from diabetes oat 
of a total number of 159 patients admitted. At the end of 
this paper I have appended the notes of these cases, either as 
complete histories of the illness, or as accounts of the fatal 
termination only. They hare been taken from the inspection- 
books and the ward-books of the hospital. Of the 43 casesj a 
complete post-mortem esamination was made in 37, in I the 
brain and spinal cord alone were examined, and in 1 the 
kidneys only. In four cases there was no autopsy. 

Table I. — Fatal Cases of Diabetes, 

Deilb b; coma, no di>MM foand part-mortam 

„ no mtopaj 

Old phthiili, comm 
RccBDt phthiiii or pneamooui comi 
Ulcaimtion of the boirel, coma . 
PjtUtil and (apparating^ kidneys. Ci 
Curbnacle, gnnnlar kidn*j, ootn* 
EilittiitioD (?), oo aatopij 

Fneoinonii 

Bright'* diiMM and peritonitU 



From this table it is seen that at least 30 cases, or two thirds of 
the total number of fatal cases died with comatose symptoms ; 
that 10 died from complications, for the most part pulmonary, 
and without comaj while 3 cases must remain uncertain, 
chiefly from want of details in the reports sufficiently accurate 
to draw conclusions from. 

The comatose cases require, however, further analysis, and 
divide themselves into several groups, according as the coma 
was the sole cause of death or was associated with one or other 
morbid condition of the viscera. There are, Brstly, 14 cases 
in which post-mortem examination revealed no disease of any 
organ of sufficient gravity to cause death, or of a kind to csuse 
coma ; in many, indeed, nothing whatever. Congestion of the 
lungs is noted in some, in others coarseness or pallor of the 
kidneys, with excess of fat, and in ] case a peculiar condition 
of the pancreas. These are all typical cases of death by nervous 
symptoms without phthisis or pneumoaia, and they form one 



, Gooj^lf 



ivith especial reference to the Death by Coma. 149 

third of the total nnmber of deaths. Bendes these there are 
3, vhich shonld nndoubtedly be classed with them, since the 
changes which were found poBt-mortem were inactive con- 
ditioDB of the lung of a phthisical nature, quite incapable iu 
themselves of bringing about a fatal result in the way it actually 
happened. In one (Case 1) the right lung presented a caseous 
mass with pigmentation and calcareous matter; in another 
(Case 15) there waa old phthisis with pleural thickening 
and pigmentatioD and caseona or calcareons nodules; and 
in the third (Case 16) a small patch of caseous induration 
undergoing calcification in each lung. The third division 
consists of 11 cases in which more or less actiTs disease of 
different organs was found post-mortem ; and amongst these 
are many in which it is not easy to determine whether the 
coma was dependent or not on the coexisting visceral lesion. 
Three had recent phthisis with cavities, 4 had pneumonia, 1 
pneumonia with gangrene, 1 had ulceration of the small 
intestine resembling that of typhoid fever, and the remaining 
8 had disease of the kidney, respectively, calculous pyelitis 
(Case 27), suppurative nephritis with dilated calices (Case 29), 
and granular degeneration (Case 29). 

No doubt most of these conditions are suEficient causes of 
death, and would have been regarded as the actual causes if 
considered apart from the clinical history ; but the question is 
whether their effects were not anticipated by the more rapid 
action of those changes which in the first group of cases were 
alone sufficient 

Tbe case is analogous to that of poisoning by an overdose of 
morphia in the course of phthisis, typhoid fever, or other 
serious disease. The post-mortem examination considered 
alone wonld lead to tbe death being attributed to the fever or 
phthisis, and the share that the morphia had in it would only be 
recognised after inquiry into the clinical symptoms. The 
analogy is all the more close because the death by coma in 
diabetes resembles in many ways the effects of poisoning, and 
has been by many attributed to the presence in the blood of a 
special product of decomposition (aceton, acetonsmia). 

Whether this he the case or not, the symptoms are to a 
certain extent characteristic, and their fatal effects are proved 
by aach cases as those forming the first group. If, then, in 



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150 On the Fatal Termination of Diabetes, 

the coarse of diabetes they supervene upoD some viaceral leaion, 
such as phthiais, aud lead as directly to a fatal terminatioii, aa 
they do when no phthisis or other lesion exists, then it is 
surely reasonable to regard them aloae, aod not the lesions 
found post-mortem, as the actual cause of death; and all the 
more if the visceral lesion in ordinary cases is not accompanied 
by any such clinical phenomena. Looked at from this point 
of view, there are some of these 11 cases which undoubtedly 
died of diabetic coma, though the autopsies aloue might attribute 
the death to visceral complications. The most unequivocal is 
Case 24. A lad, set. 14, had had diabetes for two years, and 
had been under treatmeut the greater part of that time. 
While still under the treatment and passing a large quantity of 
sugar, he was taken with abdominal pain and distension which 
were thought to be the result of indiscretions ou Christmas day. 
There was no marked oor persisteut elevation of temperature, 
no diarrhcea, and certainly nothing sufficiently characteristic 
to warrant a diagnosis of typhoid fever. Id a few days he 
became drowsy and collapsed, with reduction of temperature to 
96", and presented the characteristic picture of diabetic coma 
or collapse. The ulceration of the ileum, whatever its origin, 
was clearly not a sufficient explanation of the mode of death. 
Cases 18, 19, and 22 had pretty extensive phthisis, but I have 
set them down as having died from coma, because they appear 
to have been seized in the course of the disease with a com- 
paratively sudden development of coma, instead of continuing 
the steady down-hill course of phthisis in the ordinary way. 

There remain the cases of pneumonia and the cases of renal 
disease, both difficult to estimate rightly, on account of the 
frequency with which they end in coma, independently of 
diabetes. Of the 4 cases in which pneumonia was found 
post>mortem, it appears to me that 3 may be regarded as 
belonging to the comatose cases. They are Nos. 20, 21, aod 
S3. In the latter two, the development of the nervous sym- 
ptoms was remarkably like what it is in typical cases, and tbe 
pneumonia was relatively slight in extent. lu Case 20 the 
patient was admitted comatose, and no doubt of the connection 
with diabetes being entertained, the treatment by injection of 
a saline solution was attempted, though without success. It 
was only after death that the condition of the lung was ascer- 



.yGOOglf 



with especial r^trenee to the Death by Coma. 151 

tained. In tlie fonrth case of pneamonia terminating in coma, 
the phyaical signs of pnlmonary disease, which proved to he 
caseous pnenmoDia with cavitation, had lasted more thau two 
weeks, and coma supervened twenty-four hours hefore death. 
In the absence of an; details as to the characters of the coma, 
I have preferred to consider this case doubtful, and do not 
include it among the cases of diabetic coma proper. 

For aimilar reasons I have thought it best to place aside 
three cases with renal complications, thoogh I think it is very 
probable that one of them (Case 29) did really die of diabetes 
independently of tha chronic and apparently latent disease of 
his kidneys. Indeed, they are all recorded as " diabetic coma," 
which is at least an indication of the interpretation that was 
put on the symptoms by those who saw them at the time ; but 
as the report of one case is unfinished and the hietories of the 
other two are not very closely detailed, I cannot hope with the 
notes here appended to carry conviction to the minds of any 
one disposed to doubt their exclusively diabetic origin. As to 
the natare of the renal changes, there was in the first case 
reddening and ecchymoais of the pelvis of each kidney, with 
dilatation of the calices, suppuration of the parenchyma of one 
of them in lines along the pyramids, and depreaaed cicatrices 
CD the surface of both. In the second the esamination was 
incomplete, but as the patient had all the symptoms of renal 
cslcntaa in addition to diabetes, and as Mr. Davies-Colley had 
actually extracted a calculus from the urethra, the kidneys 
were examined. Both organs were large, white, and flabby, 
and the right pelvis, in which was a calculus the size of a pea, 
was inflamed. In the third case, that of an old man who came 
into a surgical ward for a large carbuncle, the kidneys had a 
Terj granular surface, with wasting of the cortex and thickening 
of the arteries. 

Out of the whole number of 43 cases, there are only 2 in 
which it appears that death took place from the simple exhaus- 
tion of diabetes, and without the occurrence of the condition 
known as diabetic coma. They are Cases 31 and 32. Unfor- 
tunately there was no post-mortem examination except of the 
nervous system in one of them, and this was carried out with 
reference to the question of microscopic alterations of the 
vessels and perivascular apaces in diabetes generally. 



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152 On tie Fatal Termination of Diabetes, 

If my view of theae caaea has been correct, the following 
table shows the cases classified according to tbe actual or 
efficient cause of death. 



Fatal Caiea of Diabeti 



f No Tucanl ItMoni 

J Viocenil leaioni iiuctive 

j Vitoeral leiioDi active 



Comm (diabetic ?), ranal diflaaa« 
Pnaamotiia, inflnencc of coma doablf ul 
Coma atwent. Do poit-mortsm 

Pbthiiia, pneumonia, Bright't dltaue, pel 



Of course this list does not represent all the possible causes 
of death in diabetes. Diabetics are known to be susceptible 
to the influence of fever poisonsj and one instance of this 
occurred some years ago in Guy's Hospital, when typhus was 
conamunicated by one patient to three others in tbe same 
ward i one of them had diabetes, and he died of the fever thus 
contracted. Gangrene of the extremities may also cause death, 
and moreover, diabetics may be attacked, like other people, by 
apoplexy, malignant disease, and the lesions prevalent with 
advancing age. This, at least, seems to me the only reasonable 
way to look at such cases as those mentioned by Ijecorcb^,' in 
which convulsions or paralysis occur in the course of diabetes, 

■ Id tbe ' Qnft Hospital Report* ' fbr 1876, vol. n, Dr. HUton Fagga mad* 
Boma remarki on the fatal terminatioD of diabetai, and gare the atatirtica of the 
caaea of which poit-mortem eiaminatiDni had been made in the hoapital lor the 
preeeHlog twentj-one yean, terminatiDg with the jear 187^ It will be leen that 
m; aualjBia coven a portion of hie. If I took onl; the lii jfre, 1875 to I860, 
in ardm to give ranlte which might be taken with hii. Curt i, C, 12, 28, and S8, 
amongst tbe comatose esses, and two oth«n, would have to be omitted, Tbe 
figures would then mn a* followa, and itill preaent a lai^ proportion of caaes in 
which rams was the cause of death. Thus, coma with and without Tiscenl 
leiloas, 22 ; coma with renal diuase, 2 ; doubtful cases, 8 j phtbisu, pneomonia, 
&c , without coma, 9 j total, 86. 

• ' Traili du DiabU^' Paris, 187^ 



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with especial reftrmee to the Death by Coma. 153 

in connection with cerebr&I softening and hfemorrhage. No 
doubt a lai^er number of cases would include some of these last 
instances ; but the list may be accepted as ehowing that they 
are not very common, and that the chief causes of a fatal ter- 
mination are phthisis, pneumonia, and the train of nervous 
■ymptoms nsaally known as coma. Fneamonia, apart from 
phthisis, occurred only in four cases, and three of these had 
iIm coma. These resnlts are most strongly confirmatory of 
those given by Dr. Fagge in his article already alluded to, but 
1 God that a mnch larger proportion of the deaths are due to 
corns, Dr. Fagge's figures being phthisis 21, pneumonia 11, 
coma 8, and sudden death, probably allied to the last, 2, out of 
I total of 45. 

Hitherto I have spoken of " coma " and " nervous sym- 
ptoms" without any quali&cationj bnt it will not be forgotten 
that in 1874 Knssmaul' described a " peculiar kind of death in 
diabetes" which he had seen in three cases, and which, though 
terminating in coma, was characterised by other symptoms as 
follows: — 1. A dyspnoea of a peculiar kind, consistiug in deep 
ioipirations and expirations without cyanosis or oedema, the 
respirations being at the same time I'apid and regular, but 
tiecoming slower in the stage of comsj and often accompanied 
during expiration by groaning. 2. Quickened action of the 
keart, with small, feeble, and regular pulse. 3. Great excite- 
ment, with groaning, restlessness, and violent pains. And 4. 
Coma. There can be no doubt that these observations of 
Kussmaul have directed a closer attention to the phenomena 
of death in diabetes, but, a^ might have been expected, it was 
•oon pointed out* that the newly- described symptoms under the 
fint three heads were more or less obviously present in many 
esses published prior to the date of his article, although those 
who reported them may have been content to emphasize only 
the coma, or the exhaustion, or the suddenness of a fatal termi- 
nstioB. Indeed, I think it only wants a careful observation of 
a infficient number of cases of diabetic coma to show that the 
kind of death described is by no means peculiar in the sense 
of being unusual, but is really only the most developed form of 



Dig lized^y Google 



154 On the Fatal Termtnalion of Diabetes, 

the common mode of termination, when the patient does not 
succumb to visceral complications. 

Of the cases here reported I find that more than twenty 
described as comaj or coma and collapse, clearly showed sym- 
ptoms in addition which will allow them to be classed with the 
cases described by Knssmaul and by others after him. Such 
symptoms are the abdominal pains, the laboured sighing or 
heayy breathing, the restlesBneas with moaning, screaming, or 
gToaning, semi-coma, from which the patient can be partially 
roused, collapse, pulselessness with violent action of the heart, 
dry skia and lividity from stagnating circulation. The end 
comes more or leas rapidly in different cases, with more or less 
variation in the intensity of the diflferent symptoms, with the 
predominance of coma<ia one group, of heart-failure in another, 
or of the respiratory peculiarities in a third. But from « 
coDsideration of the twenty -six cases I have grouped under the 
head of death by coma, I am inclined to think that no subdi- 
visions can be made from a clinical point of view, but that all 
gradations exist between those caaes which least resemble, and 
those which are the exact counterparts of, Eusamaul's typical 
instances. 

Senator, in a recent article on diabetes,^ seems to me to have 
adopted a similar view, including all such cases under the term 
" diabetic coma." He alludes to the early cases recorded by 
Frout, and mentions later authors, especially Russmaul, aa 
Imving given cases and descriptions. His own summsry of the 
symptoms is exceedingly good, and is here transcribed for 
further compariaon with my own cases. It is as follows : 

"Sometimes suddenly without any premonition, sometimes 
after a first stage of agitation, with general uneasiness, oppres- 
sion, anxiety, and pain in the region of the stomach, the patient 
becomes somnolent, moves about restlessly, generally groaning 
loudly. The pulse becomes frequent, the arterial tension is 
low, the breathing is hastened and deep, although there is no 
impediment in either the upper or lower portions of the respira- 
tory apparatus. The extremities become cool, and even the 
general temperature of the body falls below the natural, and, 
finally, death ensues amid the deepest coma, sometimes after 
the supervention of twitchiiigs." 

1 'ZienuuD'i Eacjclop.,' Bagl. ed.,' vol. it!, p. 916, 



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vith especial reference to the Death by Coma. 155 

These CBses are alao in accordance with the statemeot of Dr. 
W. Boberts, who Bays' that, " if diabetes does sot termiiiate by 
one of its complication a, the patient becomes gradually drowsy, 
and finally dies comatose." 

I propose now to gather, from the cases at my disposal, such 
iofbrmation as they afford with reference to the predisposing or 
eiciting caoses, and the chief clinical features of this mode of 
termination in diabetes. 

Origin of the symptomi: pathogeny. — In considering what 
cansea the outbreak of these symptoms many questtotiB sug- 
gest themseWeB. Is it the final exhaustion of the oerre centres 
which have so long been failing in their functions ? or is it 
an accidental occurrence, brought about by some external 
iafiuence in a patient otherwise promising well, or at least sta- 
tionary? Ib it due to undue accumulation of a morbid pro- 
duct already in the blood 7 or to the new formation of some 
ssch body ? or to the physical conditions of the circulating 
fluid? 

Many views have been suggested. On the side of chemical 
chsnges, the view that the symptoms are due to excess of 
acetone in the blood (acetonemia) baa received support irom 
many, while others consider them to be only a manifestation of 
uismia. Among physical theories may be mentioned the sug- 
ges^on, on which Dr. Hilton Fagge' founded an attempt to 
b^at the patients by intravenous injection of saline fluid, that 
a thiclcened condition of the blood has been brought about by 
the drun of fluid through the kidneys. Another is the more 
recent view, put forward by Dr. Sanders and Dr. Hamilton,' 
that the abundance of fat in the blood leads to fatty embolism 
of the capillaries of the lungs and other viscera. 

To take first the aceton theory, the proof of its truth pro- 
bably requires a good deal more than the clinical demonstra- 
tion of the presence of aceton about the patient, since it has 
been shown that the mere presence of a small quantity of this 
compound in the blood is insufficient to cause symptoms of the 
kind under consideration. But the cases which have been 
observed with reference to this point at Guy's Hospital have 

1 ■ Urlnnry and It«nal DiieBMB,' 3rd edit., 1876, p. 231. 
> • Qiij'b Hospital Beporta,' vol. lii, 1874, p. 178. 
■ ' EdinbarBh Mi:dical Journsl,' July, laTtf. 



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156 On the Fatal Termination of Diabetes, 

given hitherto entirely oegatire evideoce. It has been stated 
that such patients emit a atroog fragraut Hmell, like acetic ether. 
I have never observed this tnyielf, and in certainly two cases, 
Nos. 1 and 24, it was distinctly absent. In Case 13 a sweetish 
odonr was noticed in the breath, and in Caee 22 an odour like 
that of apples. Case 13 also had a sveetish odour like nitrous 
ether about him, but it is probable that in neither of these 
cases was it different trom what occurs in the earlier stages of 
diabetes. Nor was there any odour of acetone about the blood 
or viscera in the two first- mentioned cases, although they were 
most typical instances of the form of death under considera- 
tion ; but in Case 10 a sweetish odour was noticed when the 
body was opened, and in Case 7 a faint odour not unlike that 
of cats. In Case 13 the viscera were examined by Dr. Oood- 
hart and Dr. Stevenson for the presence of aceton, but with a 
negative result. 

The arguments in favour of an urtemic origin for the sym- 
ptoms seem to have as little to support them. They are the 
resemblance of the symptoms in the two cases — the diminution 
of the quantity of the urine just before death, the occurrence of 
albuminuria, and the condition of the kidneys after death. 
There are no doubt many things in common in the two condi- 
tions of coma, and perhaps in neither case such complete con- 
stancy as would make discrimination always easy. But even 
supposing they are alike, that goes a very little way towards 
proving their origin from the same cause. The diminution of 
the urine has been frequently uoticed, and I have little doubt 
that it is constant; albumen has also been present in at least 
seven cases. But I think it highly probable that one, if not 
both, of these symptoms, to which 1 shall again refer, are the 
result and not the cause of the nervous disturbance. As to the 
conditions of the kidneys, they were quite healthy iu aeventeea 
cases, and in the other seven, which make up the twenty-four, 
most typical and unequivocal cases, the changes were only 
slight, and the organs were described as " coarse kidneys," 
" large and coarse," " looking fatty," " pale and flabby, appa- 
rently fatty,*' &c. These are not conditions with which we 
commonly associate nraemie coma. As previously mentioned, I 
have grouped apart three cases in which there was pronounced 



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with especial reference to the Death by Coma. 157 

renal disease, but the; form but a amall proportion of the whole 
Dttmber of cases. 

Coining now to the physical theories, the only evidence that 
these cases afford in reference to the theory of blood thickening 
is to be found tn the results of the treatment attempted. Dr. 
Fagge's first case was partially successful ; five hours after the 
injection of a saline solution into the blood, the patient, who 
had been comatose, vith scarcely perceptible pulse, sat up in 
bed and answered questions. A case coming under my own 
care shortly afterwards was treated in the same way but without 
Boccess. Five other cases have been similarly treated at Guy's 
Hospital, in only one of which was there the slightest improve- 
ment, and that for a few hours only. 

Drs. Sanders and Hamilton, in support of their view that 
fatty embolism was the cause of the symptoms, point to the 
fatty state of the blood in diabetes, to the anatomical evidence 
of fat embola, and to the similarity of the symptoms with those 
of fat embolism after fracture. The fatty state of the blood 
has been noticed by other writers, and Br. N. Moore showed a 
spedmen of the kind at the Pathological Society in November, 
1880, bat it does not seem to be constant. In two of the pre- 
sent cases (Nos. 3 and 4) the blood is described as natural in 
appearance ; in another (Case 7) it was fluid and appeared 
healthy nnder the microscope ; and iu another (Case 5J there 
vat the nsual dec61orised clot iu the right heart. Iu two cases 
a milky condition was present. 

In Case 11 the left side of the heart contained ordinary pale 
fibrinous clot, but in the right side was " a large clot, the upper 
surface of which was milky white and of creamy consistence, 
utterly nnlike ordinary fibrin clot. Its lower surface was soft 
and roncb resembled raspberry cream. It did not staio the 
endocardium ; it seemed to cling to the fingers but did not 
ttain them," It was also very unlike ordinary red clot. The 
upper part of this clot was found both by Dr. Goodhart and by 
Dr. Mahomed to contain a large quantity of free oil-globules. 

In Case 6 the blood iu all the veins, both of the root of the 
neck and in the inferior vena cava, was opaque as if mixed with 
pus and railk, and of a lilac or purple colour. When allowed 
to stand, a white opaque cream rose from it, and this was seen 
under the microscope to contain granular matter. The left 



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158 On the Fatal Termination of Diabetes, 

aide of the heart contained natural-looking clot; the right side 
had a soft, milky-looking clot, and some liquid blood of the 
same peculiar appearance as that found in the reins. 

It may be mentioned that the blood in this case had been 
treated during life by the injection of a saline solution, but it 
cannot be urged that the creamy appearance was due to this, 
since no mention is made of a aimilar condition in the three 
other cases so treated, and in a fourth (Case 7) it is expressly 
stated that the blood vas natural in colour, and had no creamy 
layer like that present in the case of Ann £ — (No. 6), vhich 
bad occurred a short time before. This case occurred some 
years ago, and no search vas made for fat embola. 

In three cases the viscera were examined microscopically for 
fat embola with the aid of osmic acid stuning, in two cases by 
myself, and in one by Mr. G. F. Crooke. In neither case was 
anything found. 

The subject of diabetic coma is very fully discussed in a re- 
cent article by Ebstein,' who regards all these different theories 
as valid in different cases. He calls attention to the changes 
which he has found in the renal epithelium in cases of diabetes, 
consisting partly of a hyaline transformation, partly of a dis- 
appearance of the nuclei with breaking up of the protoplasm 
into lumps. He considers that this necrosis of the epithelium 
is due to the various conditions which have been recorded in 
published cases, viz. alterations in the amount of water in the 
blood and tissues, hyperglycEemia, acetonsemia, and the pre- 
sence in the blood of acetic acid, alcohol, albuminates, oxalates, 
or of fat. Once produced, this necrosis acts prejudicially by 
preventing the proper elimination of the poisons which circu- 
late in the blood-tissues as a resnlt of the morbid metamor- 
phosis, thug determining a condition analogous to, but not 
identical with, ursemia. He suggests, however, that a great 
accumulation of these poisonous products might exceed the 
powers of even healthy kidneys to excrete them. 

The predisposing and exciting causes next claim our attention; 
they include the age and sex of the patient, the duration of the 
disease, and the influence of treatment, of local injury or lesions, 
and of fatigue. 

1 ' Dcutachoa ArcLiv,' Bd, SB, Heft 2 snd 3, F«I>ruRr}, 1S81. 



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iffilh especial reference to the Death by Coma. 



159 



■^ge 1^ the patient. — It is well knowu that in patients who 
become diabetic at an early age, the prognosia ia much more 
grare than in others ; the patient is much less )ikely to be 
benefited by treatment, and the disease tends to run a rapid 
coarse. Of the fatal cases here recorded the greater projxirtion 
are under thirty years of age, and this result is largely due to 
comatose cases. 

The following table will show the relations at once, the first 
half giring the total number of patients, the total number of 
fatal cases, and the twenty-six cases distributed amongst the 
several diseases from ten to seventy years of age; and the 
■econd half showing the percentages corresponding to the 
Ggares in the first. It will be seen that while of all cases 
those under thirty form 45 per cent., they form 53j per cent, 
of the fatal cases, and 69 per cent of the comatose cases. The 
parcicnlar relation of youth to death by coma is best shown in 
tlie case of the first decade, where the difference in the per- 
centage of the total cases and the total deaths is insignificant, 
bDt becomes at once considerable — an increase of 41 per cent, 
— on comparing the latter with those dying of coma. 



^>. 


-i." 


dwtai. 


ToUl 




Denllil l>T 




Tow' 




G 
IS 
S 
2 

1 


6 
17 
10 
7 
2 
1 


48 
86 
80 
13 
9 


19-a 

60- 
198 

77 
88 


1* 
39-5 
23-2 
16-4 
46 
2-S 


IB- 
80- 
28- 
18-3 
82 














2S 


48 


169 


100- 


100- 


100- 



Sex, — The relations of sex to the fatal result in diabetes do 
not seem from these cases to call for any special remark. If 
it be attempted to compare the different sexes at different ages, 
the figures are so small that the results could not be depended 
OD. It will be sufficient here to note that the 159 cases 
admitted comprised 114 males and 45 females, giving a per- 
centage of 28 for the latter on the whole number ; while the 
fatal cases numbered 33 males and 11 females, a percentage of 



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160 Oh the Fatal Termination of Diahetea, 

25-6 Tor the Utter; snd tbe 26 deaths hj coma inchided 18 
males and S females, a percentage of 30 far the females. The 
differeuce in these figures representing the percentages is so 
little that one may say they afford no real eTidence that the 
female sex is more prone than the male sex to death from 
diabetes in general, or to the special mode of termination in 
coma. It must, of course, not be forgotten that the cases of 
patients who come to the hospital and go out partially relieTed 
cannot be contrasted with fatal cases, as one could contrast 
cured and fatal cases of typhoid. That the cases die in the 
hospital must be regarded rather in the light of an accident 
than as a result of failure in the treatment, since those who 
go out probably die within a limited period either at home or 
in some other hospital, or in the workhouse infirmary. This 
rarity of cure in diabetes considerably lessens the valne of any 
observations as to the preponderance of males or females 
among cases dying in hospital, so far as the disease itself is 
concerped ; but a larger number of cases might give conclasive 
results as to the mode in which that death took place. These 
remarks apply also, though in a less degree, to the question ol 
the patient's age. 

Duration of the diseate. — No period of the disease seemi 
exempt from the liability to a rapid termination with nerrons 
symptoms. 

Some of the present cases ran rapidly to their end within a 
• few weeks ; in other cases months or years elapsed before they 
were carried off by coma. The analysis of the first twenty-six 
cases give the following results : 



DnntidnaFUitdC* 


!»«. No.oTcuet. 


From 8 to « week* 


. 4 (Nm. 4, 7. ft 12). 


„ 2 to 6 month! 


. 6 (Ko.. 2.3.8,10,13. M). 


» 7 to la „ 


. i (JJo.. 6. 17. 19. 26). 


„ 1 to 2 ye»r« 


. 3 (No*. 1, 16. 20). 


^ Ztoi „ 


.7 (No.. 6, 14, IB, 18, 28, 2126). 


Dncertain, of wbom or 


le perlispi only 


B weeka 


. 2 (No,. 11, 21). 



It has been remarked that the mean age of these cases is 
represented by a very low figure, and it appears that some of 
the youngest cases have the shortest duration, the mean age of 

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wiik etpecial reference to the Death by Coma. 161 

the first group in the preceding table being only twenty-one 
years. In the succeeding groups the patienta are progressively 
older and older, the mean age of the second group (death 
within six months) being twenty-five, and that of the third group 
twenty-eight. It is further remarkable that of 10 cases dying 
withm lix months, 9 belong to the group of caaea iu which no 
legion was found post-mortem. To contrast with these, t!ie 
cases which certainly did not die of coma may be taken, and 
of these, S died in from three to six months, 2 in from six to 
twelve months, 1 in from one to two years, and u, or exactly one 
half, lasted more than two years. Any further analysis of this 
small list would be unprofitable. The conclusions seem to me 
that the majority of the rapid cases, or those terminating iu 
less than twelve months, died of coma ; that the majority of 
those dying of coma lasted twelve months or less; that the 
oiajority of those dying of chest disease or other complication 
alone lasted more than twelve months. 

Injtuence of treatment. — As coma developed at almost all 
periods of the disease, so it took place under the most different 
conditions as to treatment. I should, of course, apply the word 
"treatment" here to nothing which did not include strict 
dieting. Of the 26 cases, 4 were never treated by diet at all ; 
8 had been treated with more or less success at some former 
period of the illness ; and 5 were under treatment at the time. 
la the other 9 cas^a the information on this point is not suflS- 
cieutly definite. I cannot make out positively that in any case 
the nrine was entirely free from sugar whea coma came on, 
thoogh no doubt in some the disease had been more or less 
under control. For instance, in Case 1 sugar was present a 
few days before death, but the daily quantity of urine had for 
Borne time past been only two pints ; in Case 24 also the 
quantity of urine was within the normal, though, it is true, 
there was abundance of sugar; and in Case 6 it was stated by 
the friends that the patient was able to do her work well, and 
wag not troubled with polyuria, but the urine drawn from 
the bladder contained twelve grains of sugar to the ouncel 
The majority of those who had been under treatment formerly 
seem to have relapsed into their previous condition, and 
often to have relaxed in the strictness of their dieting. 
Case li was in the hospital five years before her fatal illness, 

"•"■■""■ "Google 



162 On the fhtal Terminaiion of IHabetea, 

and left vithont any sagar in the urine ; after three yean tlie 
relaxed her diet, and waa under a homoeopath. Case 20 h«d 
left the hoopital with the uriae free from sugar j ahe kept to the 
restricted diet for some time, and then auhstituted German 
black bread for the gluten bread. There was a sudden 
aggraTation of the diabetic Bymptoms with abandance of sugar 
in the urine. la one case the treatment waa never suciwufal 
in completely removing sugar £rom the urine, bat the quantity 
had probably increased, aa he had been attending regularly 
at another hospital for some time before his death. 

Amongst the cases which died of chest disease alone, there 
are 6 in which some treatment had been attempted ; 1 in whidi 
the history of treatment is doubtful ; and another in which no 
mention is made of any treatment until admission, when the 
patient already had extensive phthisis. One case had the sym- 
ptoms of phthisis for three months before those of diabetes. 

From a careful review of all these oases, I should say that 
they afforded no evidence that either treatment or the absence 
of treatment determined death in one way rather &an another. 

Influence of heal legions. — I mean by this to inquire whether 
the coma is brought on by such a distarbance to the general 
health as would be caused fay a slight blow or injury, by ton- 
sillitis, abscess in the ear, or any of the minor ailments to which 
we are all more or less subject. Among the twenty-six cases I 
only find one in which such a connection should be traced ; and 
here (Case 1) the patient suffered from headache for some days, 
and an abscess burst and discharged from the right ear the ^y 
before the serious symptoms occurred. Constipation was present 
in many cases, and might be regarded as having something to 
do with the onset. Of the severer internal lesions, such as were 
fonnd in Cases 18 to 24, one would he the less inclined to regard 
them as determining the coma the longer their duration previous 
to it. Thus, whilst the pneumonia of Cases 20, 21, 28, may 
have had a share in its cansation, this is much less likely in the 
case of the phthisis of Cases 18,19, and 21, and the bowel ulcera< 
tion of Case 24. 

Influence of fatigue. — Several writers have noticed that the 
termination by coma or sudden collapse has been preceded by 
some nnusual fatigue or exertion, and this connection was 
especially striking ia the cases mentioned by Froat and by 

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tcith especial rrference to the Death by Coma, 163 

Dr. B. Foster. The former' deacribea four cases of rapid death, 
and expressly states the individuals were in their ordinary itate 
of healtli when they left home, and that their deaths could only 
be ucribed to the fatigue incidental to travelling. Dr. Foster's^ 
cases are given in more detail. One was a man, aged thirty- 
leren, who waq thought to be improving under treatment by 
lactic acid, and spent much of his time in the open air, " going 
daily in an omnibus to the outside of the town, where he took 
a short walk into the country, and then returned home by ttie 
lame conveyance. On the day but one before he sent for me, 
be had walked farther than usual into the country, and had 
in consequence walked home a distance of some four miles. He 
arrived in a state of extreme exhanition. The next day be felt 
extremely weak, and did not go out; he took Bome purgative 
medicine which did not act." Dr. Foster saw him the following 
day, when be presented the respiratory phenomena in a high 
degree; be became gradually drowsy and comatose, and died 
eighteen hours later, so that a period of nearly three days 
elapsed between the exertion and the fatal termination. In the 
■econd case a lady, aged twenty-nine, had suffered from diabetes 
abont eighteen months. She bad arranged to go a journey of 
about twenty miles by rail, and felt quite as well as usual on 
tbe morning of her journey, and quite equal, she thought, to the 
effort. She bad some distance to drive to the railway station, 
tbe train was late, and she was fatigued by tbe extra time spent 
in reaching her friend's bouse. The following day, when Dr. 
Foster saw her, she bad well-marked respiratory symptoms, and 
died twelve hours later. Dr. Fagge also* points out that out of 
K cases that died of coma at Ouy's Hospital in the years 1851 
to IB74 inclusive, 6 died within five days of coming to the 
hospital, and he attributes the fatal termination to the fatigue 
tad excitement which the patients underwent in connection 
with the journey. It is certainly quite remarkable what a large 
proportion of those who die comatose come to the hospital only 
ft few days before their death. Of the 26 cases here analysed, 
only 4 bed been in the hospital from one to three or four 
months, whereas 14, or more than half, died within a week, and 

' 'Od stomach aod BeuHl DUeM«*,' 1848, p. 8S. 

' ■ Britiih and Foreign Med.-Chir. Baview,' Oct. 1878, p. 497. 

> 'Ouj'a Hoapilil Beporta," vol. ix, 1876, p. 180. 



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164 On the Fatal Termination of Diabetes, 

tbe remaining 4 in from eleven to sixteen dsys. But I shall 
short]; show that, though the actual coma may be of short . 
duration, there are often other indications or premonitory sym- 
ptoms of a crisis, which may be perceived a week or more 
before death ; and I believe that in at least many of the cases 
that come in and die the joomey does not stand to the death 
in the relation of caase to effect, bnt rather that the patients 
are prompted to seek admission by some sensation of illness 
and exhanstion beyond what we can perceive in them, or they 
themselves oonld describe. 

lo reference to the mere length of the jonmey, I find that 
oat of the 14 cases who died within four days of sdnuBsioo, only 
3 came from a greater distance than five or six miles. Two 
of these were already comatose and died on the day they were 
admitted, a result so rapid that it can scarcely be attributed to 
tbe joarney, when the clinical history of other cases of diabetic 
coma is iiiirly considered. I am not, however, prepared to say 
that in these cases the patient may not have undergone some 
other fatiguing exertion. More than half of the 14 patients 
came from distances of three miles or less. 

Otuet of the aymptonu. — I have already said that this is by 
no means always sudden, or even rapid. The semi-comatose 
or fully comatose condition is often preceded for some days by 
an unusual condition of ill-health; and tbe patient may 
present in this early stage, which begins irom six to nine days 
before death, one or more of the following disturbances:— 
Unusual weakness or exhaustion, loss of appetite, unusual 
constipation, slight drowsiness, breathlessness, headache, sleep- 
lessness, pain in the abdomen, epigastrium, or loins. There is, 
of coarse, little that is characteristic in these symptoms, except 
in such as are really tbe beginning of the developed condition ; 
still the occurrence of many of them together should excite 
apprehension. On looking carefully over the cases, I think it 
can be said that the fatal termination was foreshadowed by 
indications of this kind, commencing as early as four days 
before death in 8 cases, five days in 8, six days in 2, seven days 
in 2, and eight days in I. 

Tbe final stage of which the picture has been already given 
in Kussmanl's and Senator's descriptions, may develop very 
rapidly out of these preliminaiy symptoms. Patiente who 

D,gt,zec.yGOOglf 



wUk especial reference to the Death by Coma. 163 

bave only tfeen observed to be more tbaa usually weak aud 
exhansted, or bftve failed in tbeir appetite, are suddenly seized 
with laboured breathing or drowsiiiess, and sink in a few bours. 
There is, bowever, no one of these cases in vhich the coma has 
come on as absolutely sudden unconsciousness, nor has there 
in any case been a fit; and more commonly the symptoms may 
be laid to have begun from one to four days before actually 
terminating in death. As an instance we may take Case 9, a 
boy aged fifteen, who had only had symptoms of diabetes a few 
veeki. When admitted on the 18th of the month he was 
greatly exhansted, had deep and sighing respiration, and com- 
plained of sinking at the pit of the stomach. Oo the morning 
of the 21st he was much collapsed ; later in the day he was 
drowsy, but could be roused, and he died, in spite of a salioe 
iojection into the blood, on the morning of the 22nd. Case 2 
was drowsy and listless, with loss of appetite on the 4tli of the 
month, leas drowsy the following day, walked up the ward 
complaining of pain on the morning of the 6th, but in two 
or three hours more was lying in bed, not easily aroused to 
answer questions, breathing heavily with loud moaning expira- 
tions, and died in the course of the afternoon. Case 1, after 
some days of headache and constipation, during which an 
abscess discharged from the ear, was taken with sudden abdo- 
minal pun on the 18th of the month, which continued on the 
Utb, with eighing breathing, quick feeble pulse, depression of 
temperature, the patient still conscious when aroused, but 
becoming less and less observant of things going on around 
her. She died in the course of the following day. 

la Case 16 the patient had griping pains in the abdomen 
vith vomitiog and retching ou the 2nd of the month ; then a 
restless night, getting out of bed frequently ; on the 3rd he 
became semi>comatose, with deep breathing, weak pulse, cold 
extremities ; on the 4th he tried to pass water and failed, at 
midnight was insensible, but restless, and died on the 5th in 
the early morning. A more rapid course of the comatose sym- 
toms occurred in Case 17, where a patient a few days siter 
admission had facial nearalgia, accompanied by pains down the 
back and unusual weakness, with failure of the appetite. At 
T p.m. the severe pains in the back and epigastrium neces- 
sitated the application of poultices, and an hour later he was 



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166 On the Fatal Termination of Diabetes, 

fomid suddenly gasping for breath, like an asthmatic, with cold 
extremities, pinched face, small palse, nausea, aud still acute pain 
at the epigaatriam. From this time he gradually became drowsr 
and comatose, and died at four in the afternoon the next day. 

Pain. — A point of considerable interest is the occarreuce of 
more or less violent pain in a great number of cases. Kuss- 
manl called attention to this. Of his cases one had " violent 
pain in the hypogaBtrium," and another had pain " arinng in 
his inflamed stomach," as veil as " pains in the hips and hypo- 
gastrium." A large number of patients in my list have saffered 
from this symptom, and so severe was it in some cases, and bo 
suddenly developed, that it was, in combination with the 
collapse occurring at the same time, taken as evidence of a 
probable gastric or intestinal perforation. Case 1 was of this 
kind, and the pain was situated about the umbilicas and ronnd 
to the back. In Case 2i there was great pain all over, and hoi 
poultices were applied to the abdomen ; and in Case 8 there was 
great pain in the abdomen, and " it was thought she mast have 
peritonitis." Seven others had pain described as abdominal or 
" pain in the bowels," but of these, one is the patient that had 
ulceration of the ileum, and his abdomen was at the same time 
somewhat distended and tympanitic. Four had pains in the 
stomach or epigastrium, but as one is described as griping paio, 
it wag probably not confined to the epigastric region. The 
others had respectively " sinking at the pit of the stomach with 
constriction across the chest" and "pain on pressure over the 
liver and below the ribs." Altogether sixteen had this sym- 
ptom of pain, which was sometimes accompanied by retch- 
ing or actual vomiting. None are recorded to have had pains 
in the hips. In the majority nothing was found after death 
which would explain it; the abdominal viscera were normal. 
But in a few there were changes which might be regarded as 
having some connection with the pain, though perhaps not as 
the causative conditions. It is, for instance, curious that in 
the two cases in which the resemblance of the symptoms to 
those of perforation was most marked, there should have been 
found recent intussusceptions of the small intestines. I have 
never seen any statement as to the frequency with which 
these are seen in post-mortem examinations, but Dr. Goodhart 
tells me that they are by no means common; and the qaestioii 



,. GoeK^Ic 



tffith etpeeial refrntnee to the Death by 0>ma. 167 

natarally arises Tbether the pais hu been the reanlt of an 
exoetsire peristaltic actioo of the amali intestiaes, or whether 
the pain has originated in some considerable irritation of the 
■jmpathetic nervooa system, of which irritation the intassus- 
ceptioos are further eridence. 

In two other cases it is noted that there were scybala in the 
Tectum, and it may be observed that constipation is often 
antongst the early phenomena of this mode of death. Ip one 
of these the lai^e intestine was mnch distended, the transrerse 
colon was arched downwards, so that the whole abdomen was 
filled by it and the csecum and sigmoid fleznre. In the rectum 
were hard scybala, pushing out the perineum. In two other 
cases, the condition of the peritoneum suggested early inflam- 
mation, in Case S3 were some marks of recent peritonitis, and 
in Case 21 the small intestines looked injected and vascular, 
ind a little viscid fluid oonld be obtained on scraping the snr- 
fsce. The intestines here also were loaded with scybala. This 
dosely resembles a case recorded by Dr. B. Foster.' " The 
peritoneum covering the intestine and forming the omentum 
was seen to be minutely injected, the small capillaries being 
filled with red blood. There were no adhesions connected with 
the peritoneum, and no fluid in the cavity." This case, how- 
ever, as well as these two of mine in which this injection was 
observed, had inflammation in the chest, either pneumonia or 
pleurisy. In Case 24 one could not dissociate the abdominal 
pains from the ulcerative lesions in the small intestines. 
Within the last few weeks, and since I began the analysis of 
these cases, there occurred a typical case of diabetic coma under 
the care of Dr. Moxon, in which during the stage of semi-coma 
there was considerable tendemesa of the abdomen. If the sur- 
face was at all ^pressed upon she moaued, and put up her hands to 
p^vent it. The abdominal aorta was here pulsating most 
violently and out of all proportion to the apparent impulse of 
the heart J the abdomen was not distended, but rather empty, 
and the sensation of tenderness seemed to be connected with 
the oondition of the aorta. The same pulsation was present in 
the femorals and radials, and a sphygmographic tracing showed 
the almost monocrotons type of the pulse of hnmorrhage or 
aafilled vascular system. 

■ hoe. cit, p. 498. 

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1 C8 On the Fatal Termination of Diabetes, 

I have said this occurrence .of pain is of ioterest, bat it is 
also of considerable importance to know the conaection of these 
pains witli the coma or collapse of diabetes, and for this reason : 
that if an opiate is given to subdue the pain, the comatose con- 
dition which auperrencB may be wrongly attributed to the dmg, 
either by the physician or by the patient's friends. I remem- 
ber this question, whether the drowsiness was natural or due to 
opium recently administered, to have been raised in two cases 
not included in the present list. One, a boy aged nineteen, who 
came to the hospital some years ago, bad some opium given 
him just before undertaking the journey to the London, was 
already drowsy when he arrived, and died in the course of 
tweiity-foTir hours. The other, a gentleman aged thirty-five, 
who had been under my treatment some months, was seized 
one night with colicky pains, which became so severe in 
the morning that he sent for the nearest medical man, and 
was treated with opium and an enema. The bowels were 
opened, but he subsequently became unconsciouB, and died 
during the following day. He had the deep sighing breathing, 
restlessness, and groaning, seen in diabetic coma, and thoagh, 
as in the other case, the suspicion was entertained for the 
moment that the opium treatment might have been at fault, it 
was exonerated after a full consideration of all the circum- 
stancea. 

A few points of interest remain. The urine is reported 
in some cases to have diminished in quantity with the onset 
of the severe symptoms. In cases such as Nos. 3 and 3 
where death took place seven or eight days after admission, it 
is difiQcnlt to say how much of this was due to the treatment in- 
stituted and how much to the commencing failure of the func- 
tions of the body. But in Case 13 the diminution of the urine 
was noticed early before admission, and such a diminution is 
at once explained by the relation of the urinary flow to the force 
of the circulation. One of the characteristic features of diabetic 
coma is the condition of collapse, with extreme feebleness of 
the circulation, and the reduction of pressure in the kidneys 
results in a smaller quantity of urine, which may be at first 
mistaken for actual improvement. At the same time the 
quantity of sugar is leas. 
The urine contained albumen in seven cases j " some," " a 



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wilk especial reference lo the Death by Coma, 169 

little," "slightly albuminoas," in. three c&aes; a trace in two 
cases; one- fifteenth in another ; and in the last as much as two 
thirds the quantity of urine. In one only of these cases was the 
slbnminuria noticed before the comatose symptoms came on, 
and in one it was the resalt of examination of the urine taken 
from the bladder after death. In three of tbeae cases the kid- 
neys were healthy, in two fatty, in one large and coarse, and 
in the Jaat the calices were somewhat dilated, but without 
erideuce of inflammation of the organs. This waa the case in 
vhich the albumen was most abundant. Albuminuria is of 
course not rarely a complication in diabetes ; but it seems not 
impossible that the passage of albumen might be a direct result 
of the coma and collapse, especially as in one of these cases the 
duration of the disease was only a few weeks, and in three 
others was four months or less; but nearly all of the cases 
were admitted with the coma present or immediately threaten- 
ing, and no opportunity was afforded for ascertaining the 
condition of the urine just previous to the severe symptoms. 

The condition of the pupils does not appear to be either con* 
Btaat or in any way remarkable. In four cases they were 
observed to be contracted, in three dilated, and in two of 
medium size. 

Treatment. — The more certain we become of the frequency 
of coma as a termination of diabetes the more hopeless does 
its treatment become, and certainly the cases that have occurred 
at Guy's Hospital give but little encouragement to the phyai- 
ciaD who is called upon to deal with such a case. Dr. Gamgee, 
however, alludes to a case in which the symptoms were reco- 
vered from, though they returned again some time after. The 
oalf treatment besides that of stimulants (administered either 
mtemally, or as brandy by subcutaneous injection) , that has 
been at all freely tried at Guy's Hospital, has been the intra- 
venoas injection of water or saline fluids above alluded to 
(p. 141) ; the slight amount of success obtained in two 
cases has been there described. The fluids used were, in one 
case, water alone ; in three cases a mixture of sodium chlo- 
ride and sodium phosphate ; and in two cases the solution 
used by Dr. Barnes for injection in puerperal cases, consisting 
of sodium chloride two drachms, sodium phosphate six grains, 
sodium carbonate fifteen grains, and potassium chloride twdve 



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170 On the Fatal TerminatioH iff Diabett; 

grains, in two pints of water. The quantities injected ranged 
from twenty-six to forty-seven ounces. 

The cases which follow are arranged according to the 
clasaification adopted in the table on page 152. Eleren of the 
cases have appeared in prerioas volumes of these ' Reports,* and 
the shortest possible abstract is given of them, with a reference 
to the paper in which they were first recorded. 



Fatal Cases of Diabxtkb. 

Death by coma, without visceral letioni. 

Case 1. — Hannah E — , let. 28, was admitted, under Dr 
Favy's care, November 4th, 1879. Her parents are alive and 
well. Two brothers have died of phthisis, and two sisters, aged 
14 and 34, of diabetes. Two other suiters are alive and well. 
When nine or ten years of age she had scarlatina, followed by 
acute desquamative nephritis and dropsy, the latter continuing 
more or less np to the present time. She has had no other 
illness. A little more than twelve months ago ahe first 
noticed herself becoming very thirsty. She went on for five 
months without saying anything about it, and then, consulting 
a medical man, was ordered pills and a special diet. She has 
continued this to the present date, with the exception of sub- 
stituting toasted brown bread for the gluten variety. She got 
much worse irom the commencement until March last, but 
then improved, and has gained ilesh again up to the present 
time. 

She has a flushed, somewhat anxious face, light hair, grey 
eyes, waxen and moist skin. She passes urine fteqnently to 
the extent of ten or twelve pints] in the day j it has a specific 
gravity of 1040, contains much sugar, and no albumen. The 
tongue is a dark colour, bright at tip and edge, papillary 
plainly marked. Teeth bad. Appetite good. Much thirst. 
Bowels always confined. The abdomen is tense, apparently 
Bwolleu, but is not oedematous, and containing no fluid. The 
liver hard, rather enlarged. Spleen normal. Lungs normal 
Heart normal. Pulse strong, regular, quick, incompressible, 
and rather persistent. Temp. 99" ; pulse 96 ; reap. 19. 



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u>ith especial reference to the Death 4y Coma. 171 

Oa November 5th the usual diet was ordered, vith glaten, 
bran, or almond biscaits, and the foUoviag pill was given three 
times a day. 

ft Codeim, gr. i. 

Eit. Nni. Vom., gr, 1. 

Ext. Aloca, gr. j. 

Eit. Lactnce, gr. y. fUt pilnla. 

10th. — Doing irell ; codeia increased to one third of a grain. 

17th. — Codeia increased to half a grain. 

24th. — Complains of indigestion and flatulency, irith pains 
across the chest and swelling of the abdomen. 

During the month of December the urine measured from 
two to three pints, and contained from 2000 to 2700 grains of 
sugar in the twenty-four hours. The bowels were often con- 
stipated. In the beginning of January, 1880, the bowels were 
much confined, and she had headache. The constipation was 
met by the use of enema saponis, and by increasing the aloes 
and decreasing the codeia in the pill, but the headache was 
worse until an abscess developed in the right ear, and discharged 
on the 13th of the month. 

During the night of the 18th she complained of severe pain 
in the abdomen, and was utterly collapsed, so that brandy had 
to be administered. On recovering she still complained of the 
pain, which was diffused, extending round to the back, and 
worst just below the umbilicus. 

On the 14th, at 10 a.m., the face was flushed, the pulse could 
not be counted at the wrist, and was only occasionally felt. At 
12 noon it was small, thready, about 96 in the minute ; the tem- 
perature was 98'3°; resp. 26. She was lying on her back 
with the legs drawn up, frequently groaning, occasionally 
rolling over on to the side; countenance anxious; breathing 
difficult. 

I was now in charge of Dr. Pavy's wards, and I saw her 
myself at S p.m. ; she was then complaining of pain in 
the upper part of the abdomen, between the umbilicus and 
the sternum, and pointed to the sacrum as the seat of the 
pain in the back. She was conscious and rational, and partly 
turned over to show me where the pain was. The abdomen 
was tonse, but not distended, generally resonant. The breath- 
ing was deep, scarcely sighing, but as if forced. The pulse 



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172 On the Fatal Termination of Diabetea, 

was amall, thready. Pupils rather contracted. I ordered her 
beef tea, brandy and egg, by enema ; and only a little ice by 
the mouth. She had been thought by the house-physician to 
have acute peritonitis from perforation, but I felt confident 
myself that this waa only the termination of diabetes. 

At 9.30 p.m., I saw her again; she was lying on her back, 
the head and chest slightly raised. Temp. 97°; pulse 141; 
resp. SO. The breathing was now very much deeper, and 
much more closely resembled that of diabetic collapse — a deep 
inspiration, forced expiration, and then a short pause. The 
pulse was perhaps slightly fuller than at 2 p.m.; the hands 
and fingers cold and slightly livid ; the tongue brown and dry ; 
pupils contracted. She was still conscious and answered 
questions, but for the most part was unobservant of what was 
going on around her. The face was somewhat dusky, thinner 
than it was a few days previously, when she considered herself 
well. Ordered, 

9, Sp. ^h. Snip]]., Sai. 

Ammon. Cnrb., gr. vq. Aq. 3j> 4tU horil. ' 

The bowels had been open twice on the ISth and once this 
morning ; the last motion was soft and brown in colour. 

On the evening of the 13th she vomited and again at midday 
of the 14th, bringing up thirty to forty ounces of mixed fluid 
and solid of a brown colour. 

lu the course of the following day she died without any 
essential alteration in the symptoms. 

Poti-mortem. — Lungs rather congested; no signs of com- 
mencing phthisis or other lung trouble. In the small intestine 
were two small intussusceptions, evidently quite recent, if not 
post mortem ; when pulled out it could not be seen where 
they had been. The kidneys weighed 9 ounces, and looked 
healthy ; there was no shrinking of the cortex ; the stellate 
veins on the surface were plainly marked. Liver to all 
appearance healthy. Brain, heart, stomach, and spleen 
healthy. 

Ciss 2.— Sarah B— , (et. 22, admitted February, 27th, 1874. 
Duration of symptoms four months, more marked the last two 
months. No history of treatment. Dieted on admission. 
Very weak and exhausted on March 2nd. Bowels constipated. 

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with etpeeial reference to the Death by Coma, 173 

Drowsy, and listless on March 4tli. Severe abdomiaal and 
general pains on the 6th, coma with heavy breathing and moan< 
lag expirations ; death in the evening. Treatment by saline 
iDJection into the veins. Post-mortem : organs generally 
healthy, kidneys fatty, grannies in renal epithelium, stroma 
healthy. (Reported in ' Ouy's Hospital Reports,' vol. zix, 1874, 
p. 521.) 

Case 3. — William C — , set. S6, was admitted under Dr. 
Wilks iu January, 1880. He is a clerk, and haa had no illness 
before. The Bymptoms of diabetes commenced three months 
ago, and on admission he passed nine pints of urine daily. He 
was treated by dieting, codeia, and mineral acids. The daily 
quantity of urine was seven or eight pints in March and April, 
six or seven pints in the early part of May. 

On May 20th " Patient is much more drowsy than he was, 
and rather dispirited." May 23rd : has lost about four pounds 
in last two weeks ; no change in the lungs. May 26th i no lung 
mischief, no dropsy, can see perfectly well. May 27th : ordered 
to bed, being ill and feverish. May 28th : became very much 
worse towards the evening and fell into a comatose condition 
at nine o'clock; extremities cold; breathing rapid; patient 
was lying with his month partly open, eyes half closed, pupils 
dilated and equal. May 28th : is in the same condition, cannot 
be roused; breathing heavily, 30 a minut^. Water was injected 
into the veins ; it roused him somewhat, and he recognised his 
father about fifteen minutes after the injection. The tempe- 
rature at 3 p .m. was 1006°, at 6 p.m. 103-2°. He had 
slight rigors after the injection, about two o'clock. He died 
at nine p.m. Post-mortem : the organs were all healthy and 
the blood had its natural appearance. 

Case 4.— Charles C—, tet. 27, admitted May 15th, 1876. 
Symptoms of diabetes observed six weeks ago ; appears not to 
have been treated ; appetite failed two or three weeks ago, and 
bowels much con&ned lately. He is now emaciated, and 
already semi-comatose ; restless, often dozing off, but can be 
routed to answer questions; violent action of heart; feeble, 
rapid, small pulse ; deep sighing respiration ; cold surface, with 
stagnating circulation. Continued restless during the night; 



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174 On ihe Fatal Termination of DiabeteB, 

died the folloviDg moraing. Post-mortem : organs generallj 
healtbr. The cortical part of the kidoeys yellow and fatty. 
(Reported in '(iiiy's Hospital Reports/ vol. xiii, 1877, "On 
the Nervous System in Diabetes," by Dre. F, Taylor and Jas. 
F. Goodhart.) 

Case 5. — James M — , set. 38, admitted under Dr. Fagge, 
February 14th, 1873. Duration of eymptoniB nine months ; 
had never been treated. He gave up work on February 8th ; on 
the 12th his appetite failed; on the 13th he was delirious. 
Comatose on admission, with scarcely perceptible pulse, and 
slow laboured breathing. Saline injection into veins, after 
which the pulse was stronger, and he sat up to answer questions, 
and took his medicine. Continued much the same daring the 
15th, but in the evening relapsed, and died about 8.30 a.m, on 
February 16tb. Post-mortem: organs healthy ; kidneys rather 
large and coarse. (See "A Case of Diabetic Coma" by Dr. 
Hilton Fagge in ' Guy's Hospital Reports ' vol, xix, p. 173.) 

Case G. — Annie E — , set. 85, was first admitted into Guy's 
Hospital in February, 1875, and then gave a history of two 
year's thirst and free urination ; later on she had excess of 
appetite. She was two months in the hospital imprtving under 
diet and treatment. She went out and was able to do her 
work well, and was not troubled by polyuria. 

On Sunday, May 16th, her friend left her well, and had s 
telegram at three o'clock on Tuesday, the 18th, to say she waa 
ill. He found her at 4 p.m. insensible ; after much brandy 
she recognised him ; she last spoke on Wednesday, the 19th, st 
8 a.m. and was admitted into Guy's at midnight. She is well 
nourished and " does not look diabetic." The face is flushed, the 
skin warm. She is in deep coma ; the pupils equal, contracted, 
perfectly insensible to light. Breathing a little stertorous, 
respirations deep and regular, and the nostrils dilated. Temp. 
97'5°; pulse 118; resp. 25; pulse small and feeble. Urine 
drawn off, sp. gr, 1015, acid, clear, pale, sweet, containa albumen 
two thirds, and of sugar twelve grains to the ounce. Brandy 
roused her a little ; she made a few reflex movements with her 
mouth. At 4 p.m. a pint of Barnes' saline solution was in- 
jected, and at 8 p.m. a second pint. An enema of beef tea, 



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with etpeeial rttfermee to the Death hy Coma. 175 

egg, and brandy waa also administeredj but she died at 9.45 
p.m. without recovering conBcioDBueaB, 

Pott-mortem, by Dr. Fagge. — Fairly nouriihed j a little 
cedema of the ankles. Head not examined. LuugB healthy, 
except a little cedema. The posterior part of the right lung, at 
its base, iras marbled of a greenish-brown colour, and at first 
I thought it was gangrenous; but it subsequently appeared 
clear that the colour was due to the entrance of gastric con- 
tents after death. Larynx : discoloured with gastric con< 
tents (there had been no vomiting during Ufa). Heart, left 
side: natural-looking clot. Bight side: soft milky-tooking 
clot and some liquid blood, having the peculiar purple milky 
sppearauce of the blood in the venous system generally. 

Veins : in all the veins, both of the root of the neck, and 
also of the inferior vena cava, the blood had a most remarkable 
ippearance. It waa opaque, as if mixed with pns and milk, 
of a lilae or purple colour; and looked exactly like the pulpy 
liquid which sometimes oozes from a soft spleen. When 
allowed to stand a white opaque cream rose from it. This 
ander the microscope showed granular matter. The blood-cor- 
puscles were even (not crenated) ; it was thought they looked 
enlarged, and I certainly could not make out that they were 
smaller than the leacocytes, which were visible in the field of 
the microscope; but the magnifying power was insufficient to 
enable one to speak positively. 

Ileum : solitary glands rather distinct ; no tubercles. Liver 
healthy, 66 at. Spleen healthy, 6 oz. Kidneys 13} oz. 
appeared rather coarae, otherwise healthy ; some of the calices 
distinctly dilated and the pyramids flattened. Bladder mark- 
edly hypertrophied ; the bands on its inner surface much more 
risible than usual, and its muscular wall decidedly thickened. 
It was estimated as one sixth of an inch thick, the bladder 
being by no means closely contracted. 

Casi 7. — George K — , set. 18, was admitted under my care 
on May 26th, 1876. He was well lutil three weeks ago, when 
he had frontal headache, and soon afterwards noticed the usual 
tynptoma of thirst, polyuria, and emaciation. On admission 
he it much wasted and exceedingly weak ; weight 6 stone 8 
pounds ; skin dry and haiah, with motttings of greyish-brown 

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17G On the Fatal Termination of Diabetes, 

colour coreriDg the forearms, thighs, and legs, and the chest 
and upper arms to a less extent. Tongue dry and red, «ith 
yellow fur J pulse feeble, 86; urine of specific gravity 1032, 
contaiuing thirty grains of sugar to the ounce. Chest : left side 
slightly leas resonant ; hollov expiratory sound above the left 
clavicle; jerky inspiration below. Heart and liver normal' 
Abdominal aorta pulsating strongly, Bowela regular, but the 
motions have been dry. The appetite, at first voracions, has 
been failing lately. On May 28th he was ordered the special 
diet, and codeia. The following day he was tending to become 
comatose ; he could hardly talk or sit up in bed ; there was pain 
on pressure in the right hypochoudrium, just below the ribs. 
Pulse 120; temp. 97*4°; resp. 16, sighing. Tongue dry; 
thirst and hgnger abated ; pupils contracted. A. soap enema 
brought away some lumpy feces, and he vomited twice. 

On May 30th, continued stupor, with the cot^unctivie still 
senBitive, deep breathing, and feeble pulse. Temp. 94*8° ; pulse 
124; resp. 29. 

A saline solution was now injected into a vein as follows : — 
Ten ounces at 10 a.ai., seventeen ounces at 10.50 a.m., and 
twenty ounces at 6.50 p.m. No good result followed, and he 
died at 10.30 the same night. The post-mortem examination 
was made by Dr. Goodhart, and is recorded as follows : 

" Coarse features and coarse brown hair ; fair muscular deve- 
lopment ; no fat ; no dropsy ; no spots or scars. During life 
some brownish spots had been noticed, but the only evidence 
of any skin eruption now was the livid mottling from local 
stasis in the capillaries. Cranial bones normal ; dura mater 
and sinuses, &c., the same. Brain, 51 oz., firm, rather full of 
blood, and of dark colour ; convolutions healthy ; pons and 
medulla healthy. Fleurs healthy. Lungs congested ; blood in 
them rather treacly, no phthisis. Heart weighed 7j oi., 
presented the apiral form, muscular fibre good. Both sides a 
small amount of clot of ordinary character, i.e. black in the 
dependent parts and fibrinous at the upper. The right heart 
on being opened in sit4 allowed some thin serous fluid to run 
away, but there was apparently no more than the serum from 
which the blood had settled. The blood was generally fluid ia 
all the veins of the neck, &c., and in the viscera. 

" I examined the blood microscopically, and it looked in all 

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wtlh especial reference to the Death by Coma. 177 

respects bealthy. It had none of that BwoUen glassy appearance 
of the corpuscles seen in a former case of diabetes treated b; 
injection of a saline flnid. Vessels good ; both the veins into 
which the fluid had been injected looked red and ecchymosed 
in their lining membrane above the puncture^ and that on the 
right side bad a small clot in it of normal appearance. 

"When the body was opened it was noticed that it gave off 
a peculiar odour, not unlike that emanating from cats, in a 
taai d^ree. 

" Liver 49 oz., blood fluid. Gall-bladder contained good 
bile ; section very homogeneous, and wanting in lobulation ; 
dark coloured, like a child's liver. Pancreas healthy ; spleen 
healthy, 4 oz. ; kidneys healthy, 7i oz." 

Case 8.—Mary L — , ffit. 30, was admitted under Dr. Moxon 
on April 17th, 1875. The symptoms began about Christmas 
time, with excessive thirst and hanger, cramps in the legs, and 
wasting. She gave up work a fortnight ago. On admission 
■be was passing ten pints of urine; tbe heart and lungs were 
normal. On April SOth she was ordered half a grain of codeia 
three times a day. During the next few days the urine 
diminished in quantity, but she afterwards became comatose, 
and died in about three days. 

At the commencement of the severe symptoms (on April 
28th) she had pain in the abdomen, and it was thought she 
mast have peritonitis. Her hands were not cold, aud her 
poise, though feeble, could be felt. 

Po$t mortem. — Brain healthy, firm; pons and medulla 
appeared to the naked eye quite healthy. Lungs healthy ; they 
emitted a fair quantity of blood on section, and one of them 
«ome frothy fluid ; no tubercle. Liver, 51 oz., appeared healthy, 
it had not the diabetic odour. Stomach and intestines healthy, 
bnt there was an intussusception of the jejunum. Bladder not 
hypertrophied ; it contained a little creamy fluid exactly like 
pDS, but this was proved microscopically to be bladder 
epithelium detached. Fallopian tubes adherent to the ovaries; 
the left one closed and distended into a cyst. Kidneys rather 
congested, 10 oz. ; no appearance of being fatty. 

Cask 9. — Frederick P — , eet. 15, admitted under my care 
Vol. xxt. 12 

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178 On the Fatal Termination of Diabetet, 

September 18th, 1876. Symptoms began only five weeks ago; 
be has lost fleah &nd strength rapidly, and the bowels have been 
very confined. Complains of sinking at the pit of the stomach; 
feeble pulse; deep, sighing respiratioQB. Viscera apparently 
normal. His collapsed condition increased, and on the Zlst he 
became drowsy, with livid surface and cold extremities. Saline 
injection into the veins; death on the 22nd at 9 a.m. Post 
mortem : oi^ans healthy, the kidneys containing an excess of 
fat. (Reported in 'Guy's Hospital Reports' vol. xxii, 1877, 
loc. cit.) 

Case 10, — Sarah R — , cet. 30, was admitted under the care 
of Dr. Pye-Smith, August, 26th, 1879. She had not been per- 
fectly well since Christmas, and about two months ago there 
waa an alteration in her manner and temper, she became silent 
and sullen, and her appetite became ravenous. Three weeks 
ago she had jactitation of the right arm and leg, which was not 
constant, and waa never observed during sleep. Hunger and 
thirst increased and she lost flesh. On admission, there was a 
sweetish odour of the breath ; the urine was abundant, of sp. 
gr. 1045, pale and saccharine. During the next few days the 
quantity of urine fell from five pints to three. She compluned 
of severe cramping pain in the abdomen and epigastrium 
about September 3rd, and this was relieved by an enema. On 
the evening of the 4th the pain returned with inclrased inten- 
sity, and she rapidly became comatose, with slow, sighing 
respiration, small feeble pulse, and cold extremities. She died 
about 11 a.m. on the 5th. The post mortem was made by Mr. 
G. F. Crooke. 

Reddish hair, freckled face ; anaemia ; emaciation ; deficient 
development of mammse 4nd pubes. Brain healthy; the cord 
showed nothing abnormal to the naked eye. Lungs and heart 
small, weighing together 23J oz., healthy. Nothing abnormal 
to note about the abdominal viscera, except that all evolved a 
more or less sweetish odour, being quite warm when removed. 
Liver, rather pale, yellowish and mottled in places, otherwise 
healthy. The lungs, liver, and kidneys were atterwarda exa- 
mined microscopically for fatty embolism, but with a negative 
result. 

There were embola in all the pulmonary arteries compoaed 



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with especial rrference to the Death bp Coma. 179 

of red and white blood cells; no fatty particles. The epithe- 
lium of the kidney tubnlea, especially of the tnbuli recti, had 
andei^ne well-marhed fatty change ; no fatty globules in the 
blood.vesKla. The liver looked fairly healthy as regards cell 
strcctnre ; the capillaries here and there between the cellular 
network seemed abnormally widened and in many cases filled 
with blood cells and leucocytes. 

Case 11.— Alfred S— , let. 40, was admitted in October 1880. 
He had come from the country to consult Dr. Pavy for diabetes. 
He fell suddenly ill, and was brought to the hospital with 
the commencement of coma, in which he died. When seen by 
the house physician, Mr. Howell, at nine in the evening he was 
JDit sensible and could answer questions ; the pulse was about 
160, the breathing waa quick ; later on it became deeper. He 
woi quite comatose at 1 a.m. and died at five. The post 
mortem was made by Dr. Mahomed. 

Well formed, plentiful rather grey hair ; ^ick beard ; weU 
nourished. Head and spine not examined. 

Thyroid rather large, structure appeared normal. 

Lower lobea of both lungs very congested and greatly soft- 
ened. They broke down very readily, and had a etrongly- 
marked raspberry cream appearance. 

In the middle mediastinum on left side, between the peri- 
cardium and pleura, and encroaching on the left lung, was a 
nodule the size of a walnut ; on section this proved to be an 
encapsuled cheesy and creamy mass of pus, probably the remains 
of a suppurating gland. 

Bronchi slightly congested ; the small ones contained a good 
deal of frothy serum. 

Heart: muscular fibre good. Left side contained ordinary 
fit, fibrinous clot. In right side, a large clot (? two or three 
ounces) ; its upper surface was milky white, and of creamy con- 
sistence, utterly unlike ordinary fibrin clot ; its lower snrfitce 
was soft and much resembled raspberry cream. It did not stain 
the endocardium ; it seemed to cling to the fingera but did not 
stain them. It was unlike ordinary red clot and much lesa 
like fibrinous clot. 

Abdomen generally normal. Liver, averse size. Its 
lobalei Were well marked out, but there did not appear any 



180 On the Fatal Termination of Diabetes, 

increase of fibroQS tissue. Gall-bladder normal, with healtliT 
bile. 

The pancreaa presented a pecaliar appearance ; it was rather 
larger than usual ; ou its surface, and also scattered about 
the gland between the lobules, was a milky-white, fatt^-took- 
ing material, as it were smeared over it; this appearance 
extended into all the adjacent fat, notably into the transverse 
fissure of the Irrer, and into the upper part of the mesentery; 
it presented the appearance of the fatty matter seea in athe- 
roma. The lymphatic glands in the neighbourhood of the pan- 
creas and in the transverse fissure were rather enlai^ed, and 
on section appeared of a pale yellowish colour, somewhat cheesy 
looking, but perfectly homogeneous. 

Spleen soft, with much of the raspberry-cream appearance. 

Kidneys of fair size, not much enlarged considering the size 
of the man. Structure seemed normal, perhaps somewhat 
infiltrated by fat. 

Bladder normal ; not perceptibly thickened ; rugte below 
mucous membrane not particularly well marked, though jtut 
visible. 

The upper part of the blood-clot was found, both by Dr. 
Mahomed and Dr. O^wdhart, to contain " a large quantity of 
free oil globules." 

Case 12, — George E. S — , aged 25, was admitted on March 
24th, 1874. He is a letter carrier and shoemaker, aud has been 
married six weeks. He was always temperate and never had 
venereal disease. On March 8th, he felt ill, was thought to be 
suffering from a cold, and complained of thirst. Soon were 
observed polyuria, debility, and wasting. 

On March Slst, the urine was found to be saccharine. On 
this day his appetite failed aud he got rapidly worse. Mic- 
turition continued frequent. Diet was not restricted. The 
bowels acted regularly. 

25th. — Present condition : height 5 ft. to 5 ft. 1 in., weight 
7 stone j he used to weigh 10 stone. Face pinched and hollow, 
extremities cold, muscles fiabby. He complains of aching pains 
all over him and breathlessness on the least exertion, and 
these symptoms have made their appearance since admission. 

The chest is pigeon>breasted. The breathing is rather 



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mth e^eial reference to the Death by Coma. 181 

laboured, bat there ia nothing abnormal in the respiratory 
niDmittr in front or behind. Expansion and reaonance are good. 

There is a mitral BTstolic murmur audible behind and in the 
aiilla, but onl; indistinctly in front as a roughness of the first 
sound. 

Abdomen : no pain nor tenderness ; liver and spleen normal. 
He is intensely thirsty, mouth dry, tongue thickly furred and 
yellowish. Urine 13 pints 14 oances in tventy-four hours, 
slightly acid, sp, gr. 1013 ; sugar 32 grains to the ounce. 

Head ; no pain nor delirium ; sight clear ; optic discs 
healthy. There is a slightly sveetisfa odour about him like 
nitrous ether. Last night temp. 97*9"; pulse 108; resp. S2. 
Getting drowsy this afternoon ; a blister was applied to the back 
of the neck. 

26th. — Restless and wandering during the night. He was 
sick, and was noticed to have some difficulty in swallow- 
ing. Now he is collapsed, with cold surface, especially at 
the extremities; ears bine. He lies semi- comatose, with eyes 
closed, can be easily ronsed, and appears to understand what 
is said to him, though he cannot answer intelligibly ; probably 
this and the difficult deglutition are due to the parched condi- 
tion of the mouth. He is stilt reatless, but makes no com- 
plaint. He has passed 1 pint 9 ounces of urine since yesterday 
sftemoon. Much trouble to get him to take any fluid 
uonrishment. Breathing laboured, hut air euters freely all 
parts of the lung, and there are no abnormal sounds in any part. 
The resonance is good. Temperature low, resp. 24 ; pulse 65 ; 
very feeble. Fluid ran from his mouth, and brandy and hot 
drinks introduced by the stomach-pump failed to rally him. . 
The restlessness increased, he passed his urine in bed, and at 
6.10 p.m. turned on his bed, vomited, gave two or three cou- 
Tolsire gasps, and died. The post mortem was made by Dr. 
Goodhart. 

Features sharp ; brown hair; small make; muscular. Brain, 
51 OB,, rather firm, but in all respects healthy. Cord exa- 
mined carefully throughout ; at one or two places the vessels or 
spaces appeared large, hut these were mostly in the grey com- 
missare or the region of the central canal, so that it waa 
doubtful if they were really abnormal. The substance of th? 
cord seemed cjuite healthy, 

D,91,zecl.yGOOglf 



182 On the Fatal Termination of Diabetes, 

Both luDgi somewhat silky and failing to collapse } lung 
tissue healthy ; rather tough at the apioea ; and all one lung 
oedematoas. Bronchial tubes congested ; blood not thick. 

Heart, 13 oz., contracted muscle fiim. Coronary arteries 
good. Tlvula (Edematous, no other evidence of inflammation 
about the throat. 

Liver, 53 oa., with a peculiar smell, which conld hardly be 
desoiibed as sweet, about its section ; capsule thin ; organ of 
a dirty red colour ; seotioa very homogeneous, very tough, and 
of an olive-brown colour. The blood expressed from the hepatic 
vein gave no reaction when tested for sugar. 

Gall-bladder nearly empty; perhaps 1 drachm of bile. 
Spleen 8^ ounces. Cervical ganglia looked healthy. 

Kidneys, 11 oz. ; capsule adherent but not thick; very firm 
on section. Section showed thick cortex, ia which the strie 
were very well marked, but in which a closely-set arrangement 
of minute dots was to be seen, such as is to be noted ia an acute 
disorder of the kidney. What was, however, especially notice- 
able was that apart from this state it difi'ered in the great 
facility with which the two parts could be separated from each 
other by the eye, and some of that blurred state existed, evi- 
dencing disease of stroma as well as of tubes microscopically ; 
fat in the epithelial tube cells. The stroma very little fatty, 
and practically healthy. A. mere trace of albumen in the urine 
from the bladder. 

Case 18.— John S— , set. 85, was admitted March 19tb, 1879, 
with diabetes of two months' duration. He was emaciated, the 
cheeks pale, without flush. Chest fairly well formed, mobility 
equal on the two sides; respiratiou abdominal and thorado; 
resonance good in front and behind ; breathing almost bronchial 
at right apex behind; sweetish odour of breath. Ths urinO) 
which was seven or eight pints a month ago, is now between 
four or five pints, of sp. gr. 1037, containing much sugar, but 
no albumen, blood, indican, nor peptone. 

March 22ud at 3 p.m. — Feels sick this afternoon since 
dinner; bowels not opened since 14th; soap enema opened 
bowels at 8 p.m. producing loose and thin lumpy stools. 10 
p.m. pulse 112, very feeble, and collapsing. Temp. OT'S" in 
axilla, resp. 40 and laboured. Great weakness and tendency 



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ipiih eMpecial reference to the Death by Coma. 188 

to deep. Face mnoh draim, pale and cadaTerotu. ComplaioB 
much of feeling oold, and slight pain, bnt no tenderness in the 
epigastnum ; constant desire to go to stool. Gradually sank and 
died at 11 p.m. The post mortem was made by Dr. Goodhart. 

" Tbe body irhen opened exhaled a little of a pecaliar mousy 
odonr that I have observed not infrequently in diabetes, but 
there was no smell of aeetone about it. 

"Tbe brain weighed 46 oe. ; it was firm and I examined it 
and the cord in all directions, and could find nothing what- 
erer abnormal. The other viscera were quite healthy. 

"The heart weighed only 8 ounces, the kidneys 11 ounces. 
The bladder was not hypertrophied. The liver was small, and 
homogeneous on section." 

Some of the viioera were handed to Dr. Stevenson for the 
detection of acetone. Dr. Goodhart distilled some, but failed 
to rea^nise acetone in the distillate. 

Casi 14. — Alice H — , let. 18, waa admitted January yth, 
1879. The symptoms of diabetes were first notioed in 1874, and 
she had been dieted with much relief both at home and in this 
hospital. Any relaxation of the diet aggravated the symptoms, 
and they had been increasing considerably prior to admission. 

On admission she was much wasted, with enormous appe- 
tite and great thirst; the bowels regular; cheat normal; 
heart's impulse in fourth apace, fi'rst sound feeble ; urine 
abundant, sp. gr. 1028, containing no albumen but twenty 
grains of sugar to the ounce. Mental faculties clear ; pain in 
the lunibar region and between the shoulders, which she' had 
had for three weeks. 

On January 11th she complained greatly of pain in the 
abdomen, sides, and back. 

18th. — The paina were still severe. The patient was very 
veak and could not walk without assistance. 

14th.— At 2 p.m. she became delirious, and gradually sank 
into a semi-comatose condition. The pulse was imperoeptible 
in the radials, it was beating 50 per minute in the carotids ; 
the skin was cold. She died at 1 p.m. 

Pott mortem. — Lungs a little oedematous, otherwise healthy. 
Heart healthy ; blood in the heart and vessels had the usual 
appearance; it was aot lilac coloured as described in aoeto- 

D,9Z.c:,y Google 



\M On the Fatal Termnatum of Diabelet, 

memia. Liver dark coloured, otherwiBe healthy. Kidneys pale 
and flabbTj apparently fatty. Bladder markedly hypertropHied. 



Diabelet; oldphlhUu; death by coma. 

Case 15. — Daniel D — , «t, 25, vm admitted on August 2nd, 
1876. The first symptoms appeared fouryears ago, and helms 
attended for treatment both at Guy's and St. Bartholomew's 
Hospitals. Since July 28th he had passed scarcely any water, 
and has had headache and giddiness, and has felt very weak. 
He is aniemic, with light brown hair, light eyes, cold and dry 
skin. He is constantly retching, and complains of griping 
pains in the epigastrium, but he has not been sick. He has 
headache, and feels very giddy. Tongue dry and brown ; brown 
sordes on lips and teeth ; no blue line. Extensors of band not 
weakened ; sensation in upper limbo not diminished. Liver 
not observed to be enlarged. Spleen not felt. The chest 
appeared normal, with the exception of some prolonged expira- 
tion. Heart-sonnds feeble. 

August 3rd. — Yesterday complained of severe griping pains 
in the stomach and vomited. Dnring the night has not slept 
at all, and has been retching, but has not vomited. Gets out 
of bed frequently. Has passed about two ounces of water, 
which is pale yellowish green, of sp. gr. 1028; it gives a slight 
opalescence on the addition of nitric acid, and contains twenty- 
one grains of sagar to the ounce. 

4th. — Has passed a more quiet night, being semi-comatose, 
with deep breathing ; the eyes are turned upwards ; the face, 
yesterday pale, is now flushed ; weak, fluttering pulse ; extre- 
mities cold. He appears moribund. Warm fomentations have 
been applied to the abdomen ; be tried to pass water uid 
failed. Bowels not open. 

5th (12.15 a.m.),— Pulse 114,resp. 28. luseusible but rest- 
less ; moves the arms about ; conjunctivse not quite insensible, 
pupils of moderate size, equal, ha^ly act to light. TransfusioB 
of thirty-two ounces of a saline mixture ; then the pulse became 
120 and fuller, but he died at 4.30 a.m. 

Post mortem. — Brain appeared healthy. Lungs contained 
an excess of fluid. At right apex some old phtbisisj with 



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with ttpeeial reference to the Death by Coma. 185 

pleural tbickening and pigmentation; some caieons and 
calcareous nodules; no tubercles. Liver rather hard. Kid- 
neys large and coarBe> weighing 18 or 19 oonoes. Bladder 
ihoired distinct hypertrophy of its muMnilar coat. 

Casi 16.— John W— , «t. 29, was admitted on Joly 19th, 
1S76. Symptoms of diabetes had existed sixteen months. He 
was Tery much wasted, and on July 28th was very weak. 

31st. — Cheat resonant ; heart sounds normal bat feeble. 
His speech this day was slow and hesitating, and he appeared 
to be drowsy, lying down on his bed but not actually sleeping. 
The following day he could hardly get up atairs after being 
down in the grounds. In the evening he complained of pain 
in the stomach, became comatose at 8 p,m., and died at 7 the 
next morning. 

Pott mortem. — At the posterior part of the right upper lobe 
irasapatch of induration, which was caseous, and in some parts 
undeigoing calcification ; the patch was not larger than a hazel 
nut. At the extreme apex of the left lung was a similar lump, 
the size of a walnut ; it was caseous in some parts, and in others 
more or less calcified. All the other viscera were healthy. 

Case 17, — John W. B — , commercial traveller, unmarried, 
St. 25, was admitted under Dr. Moxon on September 24thj 
1880. He had scarlet fever ten years ago. Suddenly, in 
January last, he observed that he was getting thinner; noticed 
in March, that he had hunger and could not hold his water 
sll night. Extreme thirst in May ; he was then dieted. He 
has had no cough and no hemoptysis. The viscera appeared 
quite healthy. Six weeks ago was passing eight or nine pints. 
The only pain of which he has complained lus been down the 
front of the chest, and he has not got that now. 

September 27th. — Was ordered almond bread, meat, milk, 
green food. 

30th. — Some neuralgia to-day over right face, pains down 
the back, and feels great weakness. He is therefore lying on 
his bed instead of getting about the ward as usual. In the 
morning he was suffering from toothache, pain in epigastrium, 
sickness ; and he had not had his bowels open for three days. 
AAer colocynth and mercury h? had a slight solid notion, bq( 

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186 Oa the Fatal Termination ttf Dittbetti, 

no relief firom the other Bymptoms. Appetite 18 very bad to dij; 
he ate a very small chop for dlQtier, however. Face somewhat 
relieved by paiDting with tincture of aconite. Dr. Moion 
ordered tincture of gelaeminnm internally. At 5 o'clock be ate 
his tea and waa about the ward. When the clinical clerk saw 
him at 6 p.m., he aaid he thought he should get some sleep, 
having had none the previous night. At 7 p.m. he was foend 
complaining much of pain in the back and epigastrium, and hot 
fomentations were applied, by which he expressed himself as 
much relieved. Then at 8 p.m. he was found suddenly gasping 
for breath, and the house physician was sent for. He found the 
patient sitting on the side of the bed battling for breath like an 
asthmatic, with cold extremities, pinched face, small pulse, com- 
plaining of most acute pain at the epigastrium and of nausea. 
Air was found entering both lungs freely ; the heart's action 
fairly qaiet, pnlse 120, reap. 28. No teaderueas in the abdomen ; 
fair pressure relieved the pain, which vat all referred to the 
epigastrium. An injection of Horph. Acet. gr. \, and Atropin 
y4-7 v&s given. Fifteen minutes later he waa well enough to 
lie back in bed, having previously sat up to get breath. At 
10 p.m. he was sleeping, and could be easily roused ; pulse 180 
smaller, heart's action much more riolent. The patient, how- 
ever, said he was much easier ; but his breathing had the same 
characters. He was evidently sinking into a semi-comatose 
condition. 

October 1st. — At 1 o'clock he was more comatose ; at 6 o'clock 
a bad attack of breathing came on. At 2.50 p.m. the breathieg 
was shallower and he was pulseless. At 4 o'clock he died. 

Post mortem. — In the anterior part of the right upper lobe, 
just below the apex, was a oaseous mass, the size of a marble, 
with pigmentation around, and with a little calcareous mass in 
its centre. No definite tubercles existed, but the affection wss 
not altogether old, for a little opaque, puriform matter, welled np, 
perhaps out of bronchial tubes, from the margin of the mass it 
one spot. Larynx healthy. Heart : right side, mnoh fibrin and 
blood of normal colour. Intestines healthy. Hectum contained 
much scybalous fsecal matter. It was distended rather than 
contracted. Liver healthy. Kidneys coarse and fatty looking. 
Bladder reticulated by hypertrophy of its muscular coat. 



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with eBpeeial reference to the Death by Coma. 



Diabetea ; recent phthuin or pneumonia ; coma. 

C«i 18.'— Ebeaeaer F— , set. 81, was under Dr. Fa«ge on 
August 2nd, 1876. He had had symptomB of diabetes two 
fears, has recently suffered from diarrhoea, and three weeks 
ago noticed cough, with night sweats, and increasing emaciation. 
He has never been treated. On admission there were physical 
ligQs of phthisis at both apices, moat extensiTe on the right 
aide. The urine contained thirty-six grains of sugar to the 
ounce. Temp. 101-4°, pulse 120, resp. 32. He was ordered 
cod-lirer oil, cinchonine, and the restricted diet. 

On the 14th he was drowsy, and continued to be so until 
the 18th, when whilst sittii^ in a chair he appeared to hare 
been taken with serious symptoms ; he was moved into bed 
and died \a a few minntea. 

Pott mortem. — The lungs at the upper part were both 
extennvely diseased, but it was at once evident that the 
disease was different from the ordinary pneumonic phthisis of 
diabetes. There was great increase of fibrous tissue bands 
intersecting the lungs, and there were numerous scattered 
CBTities and clusters of yellow tubercles in all parts of the lung. 
Many of the vomicie had marked caseous walls. Dr. Fagge 
was unable to identify any grey tubercle. Bronchial glands 
swollen ; one or two of them contained distinct small caseous 
msBses. Larynx healthy. Intestines generally healthy, but 
in the upper part of the Jejunum a single transverse ulcer with 
indurated edge, and a little subserous tubercle. In the ileum 
one or two caseating solitary follicles. 

Case 19.— Loi^ F— , set. 28, was admitted October 2nd, 
1678, in a Bemi-comatose condition, with rapid, sighing 
breathing, and evidence of pneumonia. Symptoms of diabetes 
commenced in February; in March she was treated in Ouy's 
Hospital, and went out relieved in July. No history can be 
obtained of the beginning of her present symptoms. She died 
the day after admission. 

Brain, 46 oz., looked perfectly healthy, as well aa the spinal 

> ■ Ony'i HotpiUl Boporta,' 1S77, loc cit. 



. ,,Gooj^lf 



188 On Me Falai Termination of Diabetes, 

cord and medalla, and the vessels compared favorablf with 
those of a non-diabetic nervous system. 

Recent pleurisy in lung of right side. Left upper lobe wu 
in a state of entire disorganisation, large ragged caritiea filled 
with red grumous hut inoffenBive fluid. In the parts where 
the disease had not broken down it was a grey bepatisation in 
colour, butvaating in the solid feeling thatisnaualinanordiDsry 
pneumonia. It was more like what might be supposed to be 
the condition in a rapidly disintegrating cedema. The pttchea 
were, however, well circumscribed. Dr. Goodhart remwiied 
that it would be incorrect to call this pneumonia, of which 
there was very little. The tissue perished withont the forma- 
tion of inflammatory products. 

■ The right lung had patches of broncho-pneumonia like the 
left. Larynx healthy. Heart, 6 oz., healthy. Liver, 69 oi., 
soft not abnormal ; no unusual smell about these or any other 
parts. Kidneys, 14 oz., open textured, but not unhealthy. 
Bladder, no marked hypertrophy. 

Case 20.— Harriet H— , aet. 48, admitted December I6th, 
1875. Symptonu had'exiated fifteen months and bad been 
much relieved by treatment twelve months ago. Congh and 
emaciation the last six weeks. On admission, drowsiness, and 
complaint of pain in the left chest. Became comatose ; a saline 
flnid was injected, but she soon died. 

Post mortem. — Pneumonic patches at both bases, the left base 
partly gangrenous. Kidneys yellowish, and renal epithelium 
fatty ; other organs healthy. (Reported in ' Guy's Hosp, Rep.,' 
vol. xxii., 1877, loc. oit.) 

Case 21. — John M. — ret, 24, was admitted under Dr. Pavj's 
care January 11th, 1876. The history was given by a friend, 
who says he was well till three weeks ago. He then caught s 
violent cold, and had a great deal of coughing ; he never spit 
any blood. He has lost much flesh during this time. On 
January 6th he complained of severe pain in his bowels, whicli 
has continued ever since, becoming worse. His bowels hsre 
not been opened since that day, but were regular till then. 

He is undersized, much wasted, looks v^ry ili^ and complun* 



oy Google 



imth etpecial reference to the Death by Coma. 189 

of much pain, irhicli he refers to hU stomach, but which, he 
s&yR] he sometiineB feels in his bowels and sometinies in his 
chest. Heart normal. Lungs : at bases there is some dalness, 
with macoua r&les occasionally. Liver and spleea normal. 
Fulness on the left side of the abdomen, probably fiecal. 
Tongue dry and brownish red. 

The patient is very restlesB, and does not seem more than 
Bemi-conscions. He requires a good deal of rousing to make 
him attend to any questions, and to them generally he utters 
incoherent replies. It is impossible to get any definite infor- 
mation as to his habits ^m him. There is no history of 
syphilis. The pain he has had since the 6tfa, has been, he 
says, a^jravated by castor oil. 

9.30 p.m.— He was very restless during the evening, but is 
quieter now. He seems quite unconaciouB. He has not passed 
any water since admission. The bladder is distended up to the 
umbihcua. Between three and four pints of urine drawn off. 

January 12tb, 10 a.m. — Almost polseless, unconscious, mori- 
band. Papits widely dilated. Urine sp. gr. 1030. By boiling 
and adding nitric acid, it shows about ,V^^ albumen, and there 
are about 19 grains of sugar to the oun^. Death took place 
ihortly after noon. 

The post mortem was made by Dr. Fagge. 

Nourishment not evidently below the usual range. 

Brain, 52, healthy, so far as could be discorered. No cavities 
Tisible in the pons or medulla. Pleune : some adhesions at 
the base over the mucous cyst, to be described presently, and 
the corresponding part of the inner part of the left lung was 
consolidated, and of a creamy- yellow, granular, dry appearance. 
It was tolerably firm on pressure, and very decidedly limited 
by the lobnlar markings. It was exactly like what the apex 
of the long is often seen in diabetes — the " pnenmonic phthisis " 
of that disease. Under the microscope the pneumonia proved 
to have the characters of croupous pneumonia, the alveoli 
ituffed with inflammatory products, some fibrillated lymph and 
granolar matter, and a large number of leucocytes. 

Feritoneum. Dr. Fagge was unable to satisfy himself whether 
peritonitis was commencing or not. The small intestines, 
though not distended, yet looked injected and vascular, and 
there were some doubtful suction-lines. Scraping the parietal 



, Gooj^lf 



190 Or /A« Fatal Termination of Diabelea, 

peritoDeom with « knife, one got off a little viacid, glutinous 
fluid, not evidently opsqae. Just khove the diaphragm, 
pressing on the cesophaga* and against the Inng, was a cyst, 
the siie of a pigeon'a egg, containing an opalescent, jelly-like 
substance. Intestines healthy, no tabercle. Cfficnm mach 
dilated and distended with gas. The rest of the large intestines 
loaded in many places irith scybala. Liver and spleen healthy. 
Kidneys, 14 oi., decidedly fatty. All the tubes nnder the 
microscope found to be black with minute fatty granules. He 
cells cohered well together in long cylinders ; many of them 
were scattered loose about the field. No decided evidence of 
catarrhal swelling or multiplication of the epithelial cells conld 
be found. The bladder was dilated, not hypertrophied. 

Casb 22.— John W— , «t. 21, was admitted July 5th, 1880. 
Had good health till fonr months ago, when he was invalided 
from the army for diabetes. All the symptoms of diabetes 
were noticed fay his friends. Mve days before admission he was 
taken suddenly worse ; had to take to his bed. There has been 
noticed a slight cough of late, never any spitting of blood. 
Yesterday he was wandering in his mind ; to-day he is admitted 
unconscious. 

July 6th, — Quite oomatose, incapable of being roused ; milk 
pot into his mouth is barely swaUowed; he appears to be 
moribund. He breathes regularly and deeply. Both apices 
resonant ; expiratory sound is audible at both apices. Heart 
sounds faint. Pulse 100, full, regular. Temp. 99*. Pupils 
contracted. Breath sickly, and like the aroma of apples ; this 
odour is perceptible as far off as the next bed. No urine has 
been passed since admission (12 hours). Bladder distended. 
Urine 1021, acid, slightly saccharine, slightly atbamioons. He 
died on July 6th. The post mortem was made by the house 
physician, Dr. W. H. White. 

Lungs : some phthisis at both apices, with small cavities ; no 
tubercles to be seen ; in various parts of the long a fiew hard 
patches of a yellow colour, the lai^^t about h^f an inch in 
diameter, probably inflammatory, but possibly infhrcts ; some 
pleuritic adhesions. All the other oi^ns are healthy to the 
naked eye and not much congested. 



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with especial r^ermee to the Death by Coma. 191 

Case 23. — James H. B — , aet. 50, was admitted under Dr. 
Pavjr, Norember 1 1th, 1874. He had had aymptoma of diabetes 
three years, and appears to have liad no treatment except the 
adfice from a medical man that he should live veil. He has 
been alternately better and worse. He now passes six or 
Keren pints of urine daily, with more than 2000 grains of 
nigar. He was treated with the special diet. There was some 
cough, and moist sounds were beard overt he front of the left lung. 
December 3rd. — There is still a troublesome cough with a 
great deal of phlegm. Complains of pain in his abdomen. 

4th, — The pain in the abdomen is gone, and the cough is 
better, tboagh il troubles him at night. He has no appetite, 
refuses bis meala, and takes only liqnids. Fil. Doveri, gr. v, 
i d.s. Effervescing saline mixture. 

Sth.— Suddenly worse ; sleeping and lying in a drowsy con> 
ditioQ, 

7th. — Patient lies in a comatose state ; will speak if roused 
suffidently ; says he feels in a state of stupefaction. Pulse 
very feeble ; breathes heavily. His bowels have not been open 
lince the 2nd. 

8th. — Patient died quietly at 5.46. He was sick slightly 
before death, bringing up some dark-coloured fluid. 

Poit mortem. — Emaciation. No dropsy. Head not exa- 
mined. Right pleura, general adhesions; at lower part of 
posterior surface a hard patch, with a collection of partly 
cheesy, partly calcareous matter between the layers of the 
plenra (evidently a dried up empyema). Lnngs: all the 
posterior part of the left lower lobe in a state of grey hepatisa- 
tioQ ; the upper lobe quite free ; a little recent pleurisy of the 
surface of the affected part of the long. No phthisis in either 
bug. Heart, 12 onnces, healthy. Some atheroma of the 
mitral valve. Maoy adhesions between the liver and the sto- 
mach, and also between the spleen and the diaphragm. Liver, 
56 ounces, appeared quite natural. Spleen soft, 9 ounces. 
Kidneys, 12 ounces, rather rough on the surface ; a cyst, the 
size of a nut, containing a cheesy material, in the cortex. 
Bladder much hypertrophied ; its musonlar fibres forming 
nused bands interlacing in all directions, the mucous mem- 
brane protruding in numerous sacculi between these bands of 
I mnscidar fibres. 



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On the Vaial Ttrminatum of Diabetet, 



Diabetei ; eoma ; ulceration of ileum (typhoid X) . 

Case 24. — Ernest B — , set. 14, was admitted October 2hl, 
1878. Occupation, oewspaper boy. 

Family hittory, — Both paxeDt§ alive and bealthT. Brotben 
and siiten healthy. 

Has had measles, but in all other respects has been hesltfar 
since his birth. 

Pretent attack. — Patient fell into the river two years ago and 
received a severe fright. He vent to school for & fortniglit 
after this, and then became seriously ill and took to his bed. 
He complained of severe thirst, passed large quantities of water, 
and had pains in his head and legs. He was treated by a 
medical man, who said he bad diabetes. In about six months 
he became convalescent. Since that time be has had three 
relapses, and each time the symptoms have been more severe. 
A month ago he again became ill, suffering ft-om thirst and 
passing large quantities of urine. 

On admission he has a hot, dry skin, and flushed face. He 
cannot read with comfort, and the left pupil is contracted. The 
tongue is dry and slightly furred, the bowels regular, bat appe- 
tite bad. He vomits occasionally, and has intense thirst and 
violent pain in the abdomen, which keeps him awake at night, 
The nrine measures ten pints in twenty-four hours, is pale, of 
sp. gr. 1041, and contains 39*99 grains of sugar to the fluid 
ounce. Resp, 22, pulse 108. 

23rd. — Urine 132 ounces, sp. gr. 1035, sugar 3426 grains 
to the fluid ounce ; 4523 grains in the day. 

24th. — Urine 2 10 ounces, sp. gr, 1037, sugar 7194 grains. 
28tb. — He began diet yesterday ; has been very sick this 
morning ; violent pain in head and abdomen. Ordered opinm 
gr. ^ and Ext. Nucis Vomicie gr. \, t. d. s. 

November 1st, — Complains of great pain in the head, but 
he is up and able to walk about the ward. 

16th. — He is stronger, has gained in weight, and can go up 
and down stairs without difGculty. 

December 4th. — Is daily about the wards, has a good ap- 
petite, and generally a feeling of thirst. The nrine has a light 



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with egpeeial r^erence to the Death by Coma. 193 

yellow colour, sp. gr. 1033, no albumen, abundance of Bugar, 
The quantity of urine, which was ten pints and six pints on 
admission, fell rapidly to the normal limits ; and from October 
28th to December 12th, the average of the observations was 
two pints six ounces, the minimum being one pint two ounces, 
the maximnm two pints eighteen ounces. Daring the same 
time the sp. gr. ranged from 1027 to 1038, and the daily 
quantity of sugar from 500 to 1700 grains, only on one occa- 
sion exceeding 2000, and once 1900 grains, 

27th.— Complains of slight headache j he has not slept well 
the last two nights. There is a faint sickly odour about 
bis breath. 

29th. — He is in bed this morning ,- his head is bad ; be has 
DO appetite. The breath has a sickly sweetish smell. He 
eiplains hia symptoms by saying that he had some plum pudding 
and other luxuries on Christmas-day. 

3lBt. — He is no better ; the tongue is slightly furred; the 
appetite bad ; bowels open. Temp. 99-9° j pulse 84 ; resp. 26. 

January 2nd, 1879. — Is only passing about a piut of urine 
in the twenty-four hours. Complains of great pain in the 
head and abdomen. The abdomen is distended and tympanitic. 
Temp. 100-9° j pulse 104; resp. 30. 

3td. — He was suddenly taken ill this morning between 12 
and 1 son. His breathing is heavy and laboured ; he is propped 
Qp with pillowsj his arms extended over his head, the eyes 
prominent and staring. He complains of pain about the region 
of the heart ; he answers questions readily. At 9 a.m. his tern- 
perature was 96-8°; at 10 8.m. 96"; at 10.30 a.m. 95-8°; 
pulse 140; resp. 32. A castor-oil enema was given, and 
brought away a few small lamps of fseces ; this was followed by 
some castor oil internally. 

4th.— He has passed a very bad night, with laboured breath- 
ing. This morning he is not conscious ; lies in a semi-oomatose 
state, with eyelids half closed and eyes fixed. Temp. 98-8°; 
pulse 146 ; resp. 28. At 1 p.m. temp. 99-6° ; the pulse cannot 
be felt; resp. 34. At 6 p.m. temp. 100-3°; resp. 30. At H 
this moming ten minims of brandy was injected suhcuta- 
neoaBly, and again at 12, 3, and 5, with marked improvement 
in the condition of the pulse ; a few teaspoonfuls of milk and 
bnndy have been taken. 

VOL. XXV. ^^ 

DigtizedoyGOOglf 



194 On the Fatal Termination of iHabetea, 

5th. — Mncb ireaker thia morning. Lips pale and coTered 
Titli dry Bcalei. Radial pnlae imperceptible. Nothing aV 
normal in the cheat. Good pulsation in the carotida. Testp. 
97-7° ; reap. 84. At 13.1S noon, ten minims of brand; vete 
injected snbcutaneously, and fifteen minima at I, 2, and 4 
o'clock. He gradually aank and died at 9.10 p.m. 

The following is Dr. Goodharf a account of tfae post mortem : 
"Brain : membranes all normal except that they were excei- 
sively Toacular. The pia mater everywhere minutely injected. 
I do not attribute any signifiomce to this, aa the boy died in a 
comatose state. The brain was firm but in all respects quite 
healthy to the naked eye. I searched very carefully through 
by slicing, but could find nothing in the way of gaps or pig- 
mentaT7 deposits visible to the naked eye either in the oortei, 
the cerebral ganglia, the pons, medulla, or corpora dentata 
cerebelli. The spinal cord was injected on its surface like the 
brain, but its substance was everywhere healthy. 
" Lunge and heart healthy. Peritoneum healthy. 
" The lower half of the small intestine contained numnoos 
ulcers; they were mostly circular, as large aa a threepenny 
piece, some larger, some smaller, and much more numerous 
near the ileo-ctecal valve then higher up. I did not at first 
take them to be typhoid ulcers, because they were one and all so 
flat, hardly raised at all above the mncoua anrface, and udbc- 
companied fay any widening of their edges. They were sU 
Uaek in colour, and all occupied the whole or part of a Foyer's 
patch. At the lower part no healthy, or even unulcerated, patch 
remained, but higher up some of the patches were uniformly 
swollen by a thin layer of whitish or yellow deposit, and the 
intermediate plaques were in a state of partial ulceration, 
some of the deposit being still unsoftened; the rest of the 
mucous surface was injected, but otherwise healthy. But in 
the duodenum the mucous surface was studded over with 
irregular ecchymoscd and very superficial ulcers, to which the 
term " hcemorrhagic erosions" would well apply. The solitary 
glands low down appear to have escaped, and there was no 
disease whatever in the colon. The mesenteric glands were 
much swollen, very soft, ecchymoscd, and juicy. The pancreu 
and sapra-renals looked quite healthy. Liver lai^, but lodced 
healthy. 

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with especial reference to the Death by Coma. 195 

"Spleen large &iid brick-red in colour. The Malpighian 
oorposdea swollen and pulpy; all the tiwues rather aotl. 
Sympathetic nerves all looked quite healthy. Kidneys rather 
l^e, but quite healthy. Bladder closely contracted, and I 
dunk the muscle was thicker than normal for a boy of his age, 

" Some adductor muBcles were examined microscopically for 
Zenker's change, but none was found." 



Diabetee ; coma ; no post-morlem examination, 

Cabi 25. — George O — , set. 19, was admitted under Dr. 
Habershon's care, Slat October, 1876. Clerk. No intem- 
penuoe; no venereal disease; no recollectioD of any injury to 
bead or spine. Diabetes commenced last November or 
December, and in December Dr. Favy restricted hia diet aad 
ordered codeia; be improved, and thought himself cored in 
April, 1876, but again got unwell a month ago. He lost flesh, 
had polyuria, thirst, ravenous appetite, and thinks hia memory 
became weaker. 

On admission be is tall, thio, fair, intelligent ; height 6 ft. 
9 in-, weight 8 st. 6 lb. Skin dry, uid inclined to peel ; face 
florid now and habitoally. Tongue dry, red, clean. Heart 
and luDffs nwmal. 

Abdomrai distended and tense, 32^ inches round the umbilicus. 
Some tenderness over the stomach and at other parts of the 
abdomen. Bowels inclined to be confined. Liver normal. 
Enlarged gland in the left groin. Urine, sp. gr. 1035 ; sugar 
32 grains to the ounce. Ordered codeia and qux vomica. 

November 1st — Is very comfortable. 

2nd.— Gtets up in the evening. Bowels opened by castor 
oiL Passed nine pints of urine. 

3rd. — Passed a restless night; and in the morning was 
noticed by the nurse to be very heavy, and soarcely intelligible 
in what he said. On replacing bim in bed, be fell back hesvUy 
as though unable to support himself, and bis breathing becsme 
laboored and the extremities cold. 

9.80 a.m. — Patient on his back* breathing in a sighing manner 
though quietly; nothing like dyspnisa; ia quite unconscious of 
what may be pasting around ; though he can be loused at times 



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196 On the Fatal Termination of Diabetes, 

and then appears to understand what is said to him ; and can 
be made to drink. Extremities cold. Temp, 94*4°, pulse 74, 
fairly good. Pupils natural. One minim of croton oil was 
given him this morning, bat it has had no effect. One pint of 
liiine has been drawn off; it is of ap. gr. 1020, and contains 30 
grains of sngar to the onnce. The quantity since 10 a.m. 
yesterday is 2 pints 9 ounces. Sinapisms to calves of legs; hot 
water to the feet ; spirits of nitrous ether internally. 

S p.m. — Patient mnch the same ; a turpentine enema hu 
been given and has returned. Ordered — 

fL Ammon. Carb. gr, i. 
EIi. aq, Jiij. 4tU hone. 

f^ 01. Crotonii, n\j. Statim. 
He remained much the same till the morning of the following 
day, when the coma deepened and he died at 10 a.m. The 
purgatives never acted. There was no post-mortem examina- 
tion. 

Case 26. — George S — , tet. 33, a bricklayer, was admitted 
October 3rd, 1877. Symptoms of diabetes had existed two 
years. He had had a chancre ten years previously, and had 
drunk freely of beer all his life. 

On admission he had a feeling of weakness and dull aching 
pain in the lumbar region, and occasionally severe shooting paini 
in the bead. The complexion was florid, and the face constantly 
flushed. He was alternately drowsy and restless. The breathing 
was not obstructed, but be took very deep inspirations, and the 
movements were mostly thoracic. The lungs appeared to be 
healthy. Heart normal. Pulse 80, weak bat regular; tempe- 
rature normal. Bowels now confined, though generally regular. 
Urine highly saccharine. 

Was ordered restricted diet. The quantities of urine passed 
ou the 4tb, 5th, aud 6th October, were respectively five, eight, 
and five pints. On October 8th he was very drowsy, and com- 
plained of pain in the abdomen and diarrhoea. Urine passed 
in the preceding twenty-four hours measured four and a half 
pints. On the following day he was very drowsy, and com- 
plained much of the pain ; it was very difBcult to get correct 
answers to questions put to him. The diarrhoea was still severe; 
the urine four pints. Temperature 98°. On October 10th he 



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wiih eapeeial reference to the Death by Coma. 197 

VBs much worse, Bemi-comatose, and died at 3 o'clock in the 
afternoon. There was no poit-mortem examination. 



J>iabetet 1 coma ; renal dUeate. 

Case 27. — Charles F — , aet. 26, was always well antii he had 
gonoirbaea six months ago. Came as an out-patient here ait 
veeks ago, and was treated for gonorrhoea and orchitis ; as he 
fot well he had the first symptoms of diabetes, with polydipsia 
and polyuria. On January 2nd was passing five or six quarts, 
with much sugar, daily, and had then one grain of codeia, 
three times a-day. On January 9th the codeia was increased 
to two grains, and he appears to hare improved. 

On admission, January 11th, he looked fairly healthy. No 
excessive hunger. Urine sp. gr. 1035, containing sugar, but 
iLO albumen, though sometimes viscid mucua is passed with it. 
He was treated with opium, carbonate of ammonia, and dieting, 
and passed during the next three weeks five or six pints of urine 
ofsp. gr. 1025 to 1035. 

February 3id. — Had sudden intense lumbar pain on the left 
side, which passed off in two days. During this month the 
urine decreased to two and a half and three pints, and be gained 
sevtai pounds in weight. The acute pain recurred on February 
16th for a day, and there was a trace of blood in the urine on 
the 28th. During the first half of March his urine again 
increased to four and fire pints, and his weight fell to 103 
pounds. 

April 12th.— A calculus became impacted in the anterior end 
of the urethra, and was removed by Mr. Daviee-CoUey. 

17th. — He had severe pain over the lower part of the abdo- 
men with sickness. He could pass his water very freely ; poul- 
tices were applied ; he had little or no sleep. Temp. 100-2°. 
Treatment: opium,bicarbonate of potash, hyoscyamus; castor- 
oil enema. 

18tb. — Sickness abated; pain less j feels weak; no appetite; 
tongue rather furred ; temp, 99.2°, Takes nothing but soda 
water and a little milk. 

19th. — Sickness relieved ; much the same in other respects; 
poultices are being applied. Opium pill ; castor-oil enema^ 



198 On the Fhtal Termination of IHabetet, 

20th. — Tongue rather dry; has been delirioas all night ; is 
semi-comstoee and still rather delirions this moraing. Lies in 
bed with his legs drawn up and e;ea half open. Skin dry and 
cold. Is semi-comatose. Vomita CTerything he takes. Temp. 
97*3" ; reap. 28 ; pulse 66, thready, compressible, and inter- 
mittent. At 5 p.m. he was quite comatose, and died soon after. 

The kidneys only #ere examined. They weighed serenteen 
onnces, and were large, white, and flabby. In the pelvis of the 
right kidney was a calcalas the siee of a small pea, ttaA the 
pelvis Itself was inflamed. 

Cask 28.— Henry T— , mt. 53. Admitted May 27th, lfl74, 
under Dr. Favy. He was not severely ill ; the nrine meflsnred 
three or four pints, and its ep. gr. was 1030 or 1040. He wss 
dieted. Four days before his death he was taken inddenly ill 
with pain in the loins. He became drowsy, but could be 
roaeed. 

The post mortem was made by Dr. Fagge. Emaciation very 
moderate. There was no distinct odour about the viscera. 
Cerebral arteries ht^altby. The brain appeared quite healthy ; it 
was firm. No morbid appearance could be detected in the pons 
or medulla oblongata. Lungs quite healthy ; so trace of pneu- 
monia or phthisis, or even congestion ; emitted a fair amount of 
blood ou section. Larynx healthy. Heart 11 oz., healthy. The 
pulmonary artery contained a considerable quantity of clot ; 
ascending aorta healthy. The intestines showed distinct suction 
lines, as though there were commencing peritonitis. Stomsch 
much injected, especially towards its cardiac end, which, indeed, 
was Intensely reddened, and in spots ecchymosed. Jejunum and 
ileum quite healthy, but here and there lined with some opaque 
mucus. Large intestine dilated, otherwise healthy. Liver 68 oi., 
of natural colour, certainly not darker than normal; it gave s 
good reaction of sugar with the copper test. Pancreas normal. 
Spleen healthy, S os. Kidneys 14 os ; both were much 
congested ; the pelvis of each was much reddened, and even 
ecchymosed, and both were somewhat dilated, one more so tbsn 
the other, and Its pyramida vere hollowed oat. The cortex of 
this kidney was in a state of suppuration, presenting numratnu 
whitish-yellow points, and the suppuration extending in lines 
into the pjrramids. This kidney also presented some depressed 



with t^pteial r^ereuee to the Death by Coma. 109 

spots — the cicatrices of a former inflammation — but the; were 
very mnch more unmeroiu in the oppoute kidney, which, on 
the other hand, had no supporation. The bladder was much 
hypertrophied, its walls even a quarter of an inch thick. Its 
mncona membrane was reddened, and presented some slight 
white spots, apparently of macns, easily separable; it con- 
tained a little parulent liquid. The urethra and prostate 
appeared quite healthy ; there was certainly no stricture. The 
mucous membrane at one spot was a little rough ; this was in 
the membranous part. The testes were qnite healthy. 

Casb 2d. — Beigamin B — , set. 67, was admitted under Mr. 
Uowse's care on June 19th, 1879, suffering from a large car- 
bsncle on the back of the neck. He was found to be passing an 
exceanve quantity of saccharine nrine, of sp. gr. 10S5. On the 
21st the patient was chloroformed, and the carbnncle was 
opened, and caustic potash and chloride of zinc points were 
introduced. On the 33rd he was free from pain, but he passed 
s restless night and was delirious. The following day he 
sppeared better. His bowels, formerly confined, bad been 
opened with magnesia. Temp. 100° ; pulse 132, full, regular. 
June 25th, he became' comatose, and died so on the 26^, at 
S.30 p.m. 

Piut mortem. — Body moderately wasted. Brain, Inngs, liver, 
and spleen healthy. The heart weighed 13 ounces. The 
kidneys weighed 11 ounces; the surface was very granular, 
the cortex wasted, and opaque and yellowish in colour ; the 
arteries thickened. There was no gout in the great toe-joints. 

Cisi 30.— Henry S— , set. 20, under Dr, Pavy's care. First 
ill in September, 1874, and much relieved by treatment in 
November and December. Urine very free from sugar in 
January, 1876. Dieted till August ; disoontinuing the restric- 
tion be had a recurrence of symptoms, and then, in spite of a 
retura to diet, he had cough with blood-streaked sputum. On 
sdmisuoD in November the lungs appeared healthy, but on 
December 17th pneumonia was recognised, and he died 
Jinuary 3rd, having been comatose from the middle of the day 
before. 

Pott mvrtem. — ^There was diffuse caseons pneumonia of both 

. , Gooj^lf 



200 On the Fatal Termination of Diabttei, 

lungs, with a large cavity at the right apex. Other organs 
healthy. (Reported in ' Guy's Hospital Reports/ TOl. xxii, 1877, 
loc. cit.) 



Fatal diabetei ; exhaustion {?) ; no pott mortem. 

Case 31. — Harriet S— , et. 30, was admitted under Dr. 
Favy's care, October 2ad, 1878. Symptoms of diabetes came 
on four months ago, and she has had from time to time, iu 
addition to the usual polydipsia and polyuria, cramps and pains 
in the legs and abdomen. Lately she has had dyspnoea, and 
slight cough, and has been so weak that she has had ditBculty 
in walking about. Her hair has fallen off a great deal lately. 
Yesterday she was sick. 

On admission she is complaining of severe pains in the 
abdomen, which is distended and tympanitic. The bowels are 
constipated. Tongue moist, red, and very sore. Voice hoarse; 
slight cough ; respiration thoracic and abdominal ; rhonchi with 
both respiratory movements ; sputa dark, not abundant. 
Heart normal. Pulse small, feeble. Liver dulness increased. 
Spleen hard. Urine abundant, sp. gr. 1036, much sugar, no 
albumen. Menstruation has been irregular, and she had some 
brownish offensive discharge. The abdominal pain was much 
worse on October 4th, but better the following day. On 
October 7th she began the special diet, and the urine, which was 
8) pints daily on admission, with 4500 grains of sugar, had only 
fallen to 7 pints, with 3700 grains of sugar, on the 13th. Ob 
the 15th she took bread against orders, but was altogether bettei 
on the 17th. On the 19tb she had two attacks of diarrhcea- 
On the 25th she complained of cramping pains in the abdomen, 
and of soreness of the throat j this was found to be congested 
on the right side. October 30th, the throat continued to be 
sore. She was sleepless, and had pain over the sternum- 
November 4tb, the pain continued. November 6th, she had 
violent pains in the head. On November 7th she was much 
worse, with violent pains in the back, chest, and head, and 
great prostration, and loss of appetite. The following day she 
was sinking fast, and died on November 9th at 4 p.m. There 
was no post-mortem examination. 



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mth eapedat r^erenee to the Death by Coma. 201 

Cabe 32.— Alfred B — , Kt. 22, admitted under Dr. Moxon 
on December ISth, 1876. Duration of symptoms three years. 
Much emadatedj and very weak. The quantity of urine and 
daily amount of sugar increased until the 19th, and from that 
date there was a rapid progressive diminution from 10 to 4^ 
pints of urine, and from 9900 grains to 1000 grains of sugar. 
On the 20tli he complained of serere headache, and on the 2Srd 
TU drowqr and extremely feeble. From this date he gradually 
sank and died on the morning of the 26th ; and it is expressly 
stated in the report that he was not comatose. The brain and 
spinal cord were the only parts examined post mortem. 
(Reported in ' Guy's Hospital Reports/ vol. xxii, 1877, loc. 
cit.) 

DttUtete* ; phthisis. 

Casb 33.— Edward W— , set. 32, had had symptoms of 
diabetes four montha when he was admitted, emaciated, 
exhausted, and presenting physical signs of phthisis at both 
apices. These rapidly became more marked and exteusive, and 
he died a month after admission. There was a little recent 
pleurisy ; both lungs were in a state of caseous pneumonia, and 
the apices were converted into large ragged cavities. (Reported 
io ' Gay's Hospital Reports,' vol. xxii, 1877, loc. cit.) 

Casi 34.— Walter L— , let. 21, admitted March, 1880. 
Diabetes commenced two years and nine months ago. He was 
P»rtly dieted under Dr. Pavy's care two years ago, but would 
not adhere strictly to the treatment, and so left the hospital. 
It was probable, but not certain, that he had phthisis on his 
«ecoud admission. Six weeks later there were obvious physical 
tigns, and he died June 10th, without coma. A large cavity 
occupied the upper half of the left Inng; the presence of 
tubercle was doubtful. 

Cabi 35.— £. M— , set. 19, admitted April 4th, 1879. 
Symptoms commenced one year and nine mouths ago. He 
lias treated by dieting in Guy's for some time, but five months 
»e<i he returned to ordinary food. Admitted with evidence of 
phthisis. She died June 5th, and the lungs were found extea- 



„Gooj^lf 



202 Omtlie fktat TermiMUiom ^ DUtMe$, 

nvelT diaemsed, i luge cavity occupying the light app«r lobe, 
with thin walls, aad shreddy slooghs adhering. In the left 
upper lobe were uft rounded nodnles of creamy yellow eaa- 
siatenoe, cmittiDg a craamy porifona fluid on prennre. No 
taborclea. 

Cua 86.— Charies S— , nt 82, admitted in January, 1879. 
Diabetes first noticed about May, 1877; a year later waa nader 
diet treatment at Guy's Hospital, the lungs being then heattiiy. 
Shortneas of breath was noticed in May, 1879, but the diest 
appearedhealthy as late as June, 1879. In Jaly phthisis beesme 
wdl marked and he died in NoTember. Both lungs were 
extensirely affected with a pneumonic form of phthisii, the 
spper parts suffering more than the lower. In the eertiaal 
region of the spinal cord was an absoesa, occupying chiefly the 
grey matter, and without any indication of yellow tubercle. 

CAsa 87. — D — , »t. 41, had symptoms of diabetes in 
October, 1878, and was dieted from October, 1874, to Febrasry, 
1876. His lungs appear to hare been healthy in December, 
1875, but phthisis was obvious in February, 1876, and he died 
two months later, with .symptoms of ideurisy. There wu 
extenuve phthisical disease in patches and clusters of what 
might have been either yellow tubercle or caseous pneumonia; 
in some places scattered grey tubercles ; and in one upper lobe 
hepatisation breaking down into a gangrenous pulp. 

Casx 88. — Oeoi^ W— , at 84, had had diabetes two years, 
and was admitted with signs of phthisis, of whieh be died s 
month later. Sugar was absent ftt>m his urine shortly before 
death. He appears to have had no treatment before admiision. 
The right Inng was pneumonic firom apex to base, but had s 
large cavity just below the apex, and there were some smsll 
cavities at the left base. 

Casi d^.—'W-m., nt 47. The symptoms of diabetes appeared 
ten months before death, but were preoeded for three moathi 
}]j the phthisis of whieh he ultimately died. 

Cask 40. — James C— , let. 46. The disease had a domtioD 

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with especial reference lo the Death bg Coma. 208 

of eigbt montlis from commencemeiit to tenninatioD. Id the 
third month the Inngs were healthy ; a month later he bad aome 
congb ; in the seventh month there was decided Blight phthisis, 
and this became more marked until his death. 

Tbe right Inng was found extensively esvitated above, and 
elsewhere tough and yellowish &om infiltration with pneamonic 
products. In the left lung the disease was scattered and 
nodnlar. (Reported in ' Guy's Hospital Reports,' vol. xxii, 
1877, loc. cit.) 

Diabetes / pneumonia. 

Cams 41. — Lacy K — , mt. 25, was admitted on Mftrch lat, 
1876. Symptoms of diabetes had existed aboat a year. She 
vu passing eight pints of nrine in twenty-foar hours, bat 
nnder treatment it fell to four or five pints daily. She 
remained fairly well till May 4th, when she ailed a little and 
said she had taken cold. On the 6th a pleuritic rub was 
heard at the base of the right lung ; she was very restless and 
strange in the head, her breathing became more impeded, and 
she died soddenly the next morning at 7.30 a.m. 

Pott mortem. — The blood had a peculiar moasy smell. Its 
colour and coagulability presented no alteration. Both longs 
were tedematoufl, and the right middle lobe was in a state of 
&cate pneumonia ; it was not gangrenous. Liver 80 oz., homo- 
geneotu in appearance. Kidneys weighed 14 oz. Bladder a 
little dilated. (Reported in ' Guy's Hospital Reports,' vol. xxii, 
1877, loc. cit.) 

Cur 4S. — Thomas C — , set. 43. Died with pulmonary sym- 
ptoms. There was recent pleuritic lymph on the back and 
Bides of the lower lobes of both lungs ; cheesy nodules in both 
apices ; no tubercle. At the anterior inferior angle of each 
lover lobe a patch of grey hepatisation breaking down into 
minute abscesses. 



Diabetes ; tjfpiilU/ tvppta-ative peritomtU. 
Cask 43.— Thomas R — , tet, 30. Duration of illness about 

. „Gooj^lf 



204 On the Fatal Terminatitm of DiaMei, 

twelve months. Had pol^ria, with sugar and albmnen in the 
urine, great thirst, oedema of the feet, l^s, and scrotam. 
Was relieved by treatment and diet, Oa re-admission had peri- 
tonitis, and died. 

Poii mortem, — Acute suppurative peritonitis. Enlarged liver, 
weighing 108 oz., and containing three small 8;^hilomata. 
Spleen, 24 oz., lardaceous. Kidneys, 22 oz., mottled yellov, 
with scattered, depressed marks from local wasting. 



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OBSERVATIONS 

TABIOITS FOBMS OF SUPERPIOIAL 
DERMATITIS, 

PiBTICCLiBLY 

ERYTHEMA, ECZEMA, PSORIASIS, LICHEN, 
AND PITYRIASIS RUBRA. 

WITH CASES. 



By p. H. PTE-SMITH. M.D. 



Thb inflaminatory affections of the skin are by far the most 
numerotis aud the most common, and it ie here that all 
■jstematic writers have found the greatest difficulty. The 
clascification now most generally accepted, that of the late 
Professor Hebm, was based upon the pathological doctrines of 
Roldtansky. Accordingly, we find a class Exddations, which 
takes up just half of the closely-printed pages of the ' Haut- 
krankheiten,' and yet does not include lupua, nor alcera, nor 
inflammations due to syphilis. The suhdiTisions of this un- 
wieldy class rest for the most part, not on pathological dis- 
tinctions, but on the anatomical basis of Willan's system, 
while scabies is only separated from eczema by its ce/t'i 
and pityriasis rubra is defined by its clinical features. 



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206 Ob$ervationt on the Variout Formt 

I have, in a former volume of these reports,' given reatona 
against this and the many other less successfol attemptB to 
classify diseases. These must always be attempts to dsssify 
objects which are not homogeneoos, sometimes not even deSn- 
able. If, however, we recognise the different aspects in which 
" diseases " may be regarded^ we may usefully recognise the 
points in which they agree under each head, whether regarded 
as anatomical conditions, as physiological processes, ss con- 
stant clinical combinations of symptoms, as results of ante- 
cedent causes, or, lastly, as amenable to curative agents. The 
first or histological method is useful fat definition, the secoQd 
or pathological for prognosis, the third or clinical for diagnoais, 
the foarth or letiological for prevention, and the last or thera- 
peutical for treatment. 

Applying this principle to Dermatitis, we may first draw a 
marked distinction between the mtperficial infiammationt, which 
affect the Malpighian layer of the epidermis and papillary layer 
of the cutis only, which never destroy the papille, and sie 
therefore never followed by a scar, and the efeep inflammatumt, 
which affect the subpapillary layer of the cutis and the sub- 
cutaneous connective tissue, which destroy the papilla, acd 
always leave cicatrices behind. To the former group belong 
all the common superficial inflammatioas of the skin of which 
eczema is the type, to the latter the deeper and more formid- 
able lesions like lupus and tertiary syphilis. In both groups 
we distinguish traumatic inflammations, doe to a known 
external irritant or injury, firom those which are iymptomatk of 
a more general pathological process, or which ai« indepwdeDt 
and of unknown cause, i.e. idiopathic. Thus, among superfidsl 
inflammations, we diatingnish Scabies and Eczema solare, and 
Prurigo pedicularis, as traumatic, &om the symptomatic erup- 
tions doe to Scarlatina or to Syphilis, and tiom those which 
depend on some unknown condition of skin itself. And in like 
manner we distinguish the deep inflammation caused by a bun 
from that due to the formation of gummata or of tubercle 
beneath the papilla of the cutis, and frY>m the aatochthonoiu 
proeeaaes of Leprosy or of Lupus. 

Confining our attention to the more numerous and difficult 

> Third Mriu, vol. ixLi, p. IGl. 

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9/ Superficial Dermatitis. 207 

group of BHpo^cial iafluamatioiu of the skin, we have no 
difficulty in Beparatmg £rom the rest bo well-marked nod 
peculiar a disease aa Zona, the ioflammatioiM dae to Sy^lii, 
the mB^y sltglLt inflammatitms oaiiaed by the preaeoce of • 
paraaitic fnngoa, ^d ^e speoal effect* due to Termin, Sntbiea 
and Prurigo pedicDlaria. The remainder, regarded clinically 
u well as phyaiolo^callyj appear to Call into the following 
large diviaioDS : 

1. Symptomatic EruptioDB, inclading the Exanthemata and 
Syphilodermift. These soaroeiy need tneatment as eruptions, 
but are of valoe for recognition of ihe diseaae of w^kk they 
are parts. 

2. Allied to t^ese aa not beiag traumatic are the Erytiiema- 
tonB rashae, which also agree with moat of tin firat cdaaa (as 
meacdeB, Bcarlatina, enterica) in l^eir anatomic^ diaracterB, 
bat difl^ by being BOt oertainly aaaotriated witii any other 
morbid cosditi^B. They resemUe each other in their slight 
d^ree of eeverityj tbeir Aigitive eonne, tiieir wide and 
capricionfi dlBtribation, and their greater frequency among the 
youBg. 

8. Common supeificaal denaatitiB, i,e. awA. aa can be pro- 
dvoed in the great mqority of skins by an appTO|»iate irritant. 
Usually tetumHtic in wigin, but probably always ctHubined 
with a cea>tain mlseralniity which vetponda readily to irratants, 
irhieh keeps up the dermatitis when the excitii^ cause has 
piBsed, and which sometimes seema sufficient alone to pro- 
duce a spontaneoBS or idiopal^ic dmuatitiB. This group 
inclBdes all varieties o[ Eczema. 

4. A group of which FsoTiaais is the type and almmt the 
*oIe representative, peculiar in histology and in form, incapable 
of bong produced by any known irritant, slow in progress, apt 
to reeur, d(£nite in disbibutiDn, unconueoted with internal 
at with external oaoses, and with its iDflammat<M7 character 
but dightly marked. 

5. Lastly, there »e the rare, but most interesting, oaaea of 
luperfidal dermatitia, which are nniversal, which differ irom 
other diseases in their form, which are often accompanied with 
pyrexia, albuminnria, and other signs of general disturbance, 
and which not on&eqaeutly and &tally.' 

' 0( pnaphigu, tha nuMt Importut of th* idlopsthie lopwflaisl inflMntutiona 

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308 Obaervationg on Superficial Dermatitu. 

Id the following pages I propose to record cases and offer 
obsemtions oa Erythema and its allies, on Eczema and trau- 
matic dermatitis, on Psoriasis and the interesting disease 
known as laehen ptanus, and, lastly, on the Pityriani rubra of 
Hebra and exfoliatire dermatitis of Wilson. 



I. EnVTHBHA. 

If we define erythema anatomicaUy as a enperficial dermatitis 
which does not go beyond the stage of papules, it is impossible 
to recognise it as a disease. For the term will then include 
scarlatina and measles, syphilis and euterica, many cases of 
scabies, and most of prurigo. If, however, we fix our attention 
on clinical and not only on anatomical features, we shall, 1 
think, admit a natm-al family of affections of the skin — for the 
most part obscure in origin, and chiefiy important for their 
resemblance to more serious maladies— which may be fairif 
called the erythematous group. 

We must, however, separate off such slight local dermatitis, 
set up by external irritants, as intertrigo and the so-called 
Erythema leve of anasarca. These bear the same relation to 
idiopathic eruptions of the same kind, as Eczema solare to true 
idiopathic Eczema, as pustular inflammation from pedicoli 
capitis to ordinary impetigo of the scalp, or as wheals caused 
by a stick or a nettle or a caterpillar, to idiopathic urticaria. 

Next must be separated cases of abortive or papular eczema, 
which may be identified by their recurrence, Uieir localisa- 
tion, and by their being preceded or followed by ordinarr 
"moist tetter." 

Thirdly, we exclude erythema where it is merely a con- 
comitant of another primary external lesion, as in prurigo, 
where the erythema or urticaria so often seen is the result of 
the patient's scratching. 

Fourthly, we put in a separate group erythema which is 
merely a symptom of an internal primary disease, as in measles. 

Is the remaining group of idiopathic non-contagions Erythe- 
mata natural and homogeneous ? 

.a k fatnrc 



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Erythema. 209 

If ve tnm to Willaa's species of Roseola and Erythema, we 
shall find no real pathological distinction between them, except 
in the case of Erythema nodosum. Nor do I think that 
Hebra made a valid distinction between mere hypenemia 
(under which he includes several unimportaot forms of roseola 
and erythema) and inflammatory Erythema (E. exudativum). 

" Roseola," if the term is to be kept at all, should mean a 
rose-rash without papules, due to whatever cause. Hebra 
iuclndes two varieties of " Erythema," E. muU\forme and E. 
nedotum. To these may, a« clinical allies, be added Urticaria, 
and two erythematous inflammations of the skiu, which go 
beyond the stage of papules : Erythema (or Herpet) irit and 
ErythtTna buUosum. 

The erythematous group of diseases tbos formed agree in 
the following points : — In their acute or at least sabacate 
course; in not spreading; in frequent return under similar 
conditionH ; in causing considerable local irritation ; and in 
leaving no trace behind. They resemble the rashes of measles 
and early syphilis by a patchy and irregular distribution. 
They rarely affect the scalp or the flexures of the joints. 
They are more often seen in children and young adults than 
in those who have past their prime. The anatomical condition 
is one of active hypenemia, often accompanied with acate 
(sdema so as to form wheals, and occasionally producing 
pimples, vesicles, or blebs. When the congestion is chronic and 
venous, the oedema may be accompanied with bsemorrbage, 
aa in Erythema nodotum. 

We know little of the causes of these diseases and less of 
their rational treatment. They are seldom or never due to an 
eitemal irritant, but some cases of general erythema and of 
urticaria are undoubtedly connected with gastric irritation from 
certain articles of food or from drugs; and this fact makes 
it probable that other apparently similar cases (especially in 
children) are also due to slight gastric distorbance. Aguu, 
some cases of urticaria, of ordinary erythema (peliosis), and 
of erythema nodosum, are coincident with attacks of rheumatic 
fever. 

All dermat'-logists of experience admit the close cHuical con- 
nection between ordinary erythema and urticaria. I need, 
therefore, give no cases in illustration of it; but will here 

Tot. XXT. 14 /^ , I 

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210 Obaervations on Superficial Dermatitu, 

record a few examples of the rarer erTtbematOTU affi^ons 
which are attended with Tcsicles or blebs. 

Veticular or htrpttie aythema. — The outbreak of a little 
gronp of clear veaicles on a.n inflamed patch of akin ia not 
enough to (xtnstitnte a diseaae, and there is nothing bat an 
anatomical likeness between the several " species" of Herpes 
which have beea admitted by authors. Willan recognised the 
distinctive characters of a herpetic emption and rightly defined 
it from the anatomical point of view. The species of the genns 
given by Willan and Bateman are H. pfUyctanodeM, H. lotltr, 
H. circinalus, H. labialia, H. praputialia, viA H.irU. The first 
of these, preceded by two or three days' fever, irregular 
in locality, and appearing in snccesaiTe cloaters for nearly 
the space of a week, may probably refer to zona occorring in 
other regions than the cheat. The third is ringworm of the 
body. Hebra admits the remaining four species, H, UdnaiU vel 
facialis, H. praputialis vel progeniialis, H. zoster vel zona, and 
H. iria, including non-parasitic circinate forms. The patho- 
logical characters which he gives as common to these varieties 
are their acute, typical course, their spontaoeoiu involntioD, 
and their recurrence at regular intervals. That they are all 
rapid in their course and curable without interference, is no 
doubt true, but this is surely not enough to outweigh the 
marked clinical differences between H, labia&» and S. zo$ter. 
Herpes of the face and Herpes of the genitals agree in 
sometimes recurring, but recurrence of Kona is at least as 
rare as that of scarlatina. Most modern dermatologists there- 
fore separate Zoster (or zona) altogether, in name as in nature, 
from Herpes. The rare and curious affection called Herpes 
iris is best grouped with Erythema, as Kayei taught long ago. 
It may be called £lrylhema iris with Neumann, or simply 
Iria. One word is better than two, it is distinctive and doe> 
not at all events mislead. 

The two remaining species of Willan and Bateman may be 
well united under the name Herpes, the locality affected being 
indicated by an adjective. This has been done abready by Dr. 
Liveing and other good observers, who have called tfaem febrile, 
catarrhal, or symptomatic Herpes. Beside the well-known 
anatomical appearance of the lesion, this disease is characteriwd 

D,91,zecl.yGOOglf 



Erythema. 211 

by its aCDte conrae, b; its spontaneous core, hj its localisation 
in the neighboarhood of one of the orifices of the body— the 
nostrils, month, nrethra or ear — by its not being accompanied 
by neuralgia, by its freqnent recurrence, and by its association 
with irritation of the cavities near which it appears. 1 am not 
awiire that it has ever been obserred in the neighbourhood of 
the rectum, but from its painless and rapid course it would be 
apt, if it did occur here, to be overlooked. 

Erythema in$. — Cabb. — One of our stndeuts, a young man 
in TigorouB health, came to me with a perfect example of the 
datsical "Herpes iris " upon the back of his hand. It measured 
in inch in diameter and consisted of a bulla in the centre, a circle 
of Teiicles, then a well marked injected circle, and lastly, an 
imperfect vesicular circle at the circumference of the patch. It 
Tu unattended irith pain or notable irritation, and disappeared 
in a week. There was no ground for connecting it with indi- 
geitjon or with any local irritant, and there was no rheumatic 
hiiiory, direct or indirect. 

Another cose of typical Iris occurred in the practice of Mr. 
Waren Tay, which be was kind enough to send for me to see. 
The patient was a boy of thirteen very sutiject to chilblains. 
Beside bullous erythema of the feet and ears he had two Iris 
circles on the back of one hand. 

I have now under my care s similar case of B. bullotum and 
iria in a lad of seventeen.^ 

B. buUotum is often a mere variety of E, conffettivum or 
ptTTuo, One sees occasionally cases which resemble a broken 
chilblain in appearance, but which differ from it by their 
localization, or their occurrence apart from cold, or their more 
rapid course. 

Case. — A well-nourished, healthy shop-girl came to me on 
the ISth of May, 1879, with livid, swollen, pemio-like patches 
on the fingers, the back of the bands, and the palms. Several 
had small bullee upon them. She said that she had never 
suffered firom chilblains of the bands or feet. 

I have seen several other cases, both of ordinary chilblain 

' Dr. Frederick Tsjlor and Dr. Crocker have lately broagbt levornl cnseg of 
TBDcnki and bnllooi Erythema, Hjdroa, or Herpoi icit before the Clinical 
SKietj (fab. SK, 1B81). 



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212 Obiervationi OH Superficial DermaiUts. 

and of bulloQB erythema not apparently connected with oM, 
affectiog tbe palms of the hands and the soles of the feet. In 
one child of five years both soles were severely affected, a Imba 
bad formed in tbe thigh, and it looked at first sight not unlike 
a bullous syphilide. 

Case, — In June, 1879, a girl of 18, came to me on account 
of a distressing "flushing" of both cheeks. There vu a 
permauent erythematous patch on tbe left cheek, livid in 
colour, with slightly enlarged veins. I was assured that occa- 
sionally little bladders formed on such a red patch ou theclieek 
or nose, and exuded a little clear watery liquid. Three weeks 
later she came again to prove the correctness of the statement, 
by showing me four or five vesicles on an injected patch on the 
right cheek. These were as big as split peas, and one had 
already burst, exuding a drop of transparent yellow senun. 
The skin was not thickened. There was an erythematois 
patch on the other cheek also. I could find no connection of 
this troublesome disorder vrith the menstrual function, but the 
patient was subject to flatulent dyspepsia, and also to chilblains 
(of the feet only) in winter, I advised strict diet and horse 
exercise, and prescribed alkalies and laxatives, with the local 
application of collodion. The latter application, she told 
me afterwards, often stopped it when she was sure it was going 
to appear by tbe premonitory flushing and tingling of the fsce. 

A curious erythematous affection has been recorded by Mr. 
Morrant Baker, the late Dr. Tilbury Fox, Dr. Sangster, and Dr. 
Cavafy, under the name Urticaria pigmeniota. 

Case. — Dr. Ooodbart was kind enough to send me a case of 
this disease from the Evelina hospital. Solomon G — , a child 
of two years old, has, &om the age of three months, been 
affected with an eruption of rather large, discrete, yellowish- 
browD papules. They cover the greater part of the back, cheat, 
abdomen, and adjacent parts of the arms and thighs. The hands 
and feet and the head and neck are free. The rash was' not 
affected by the process of teething. There vere two or three 
fresh wheals of urticaria with erythematous injection around. 

I have seen two very similar cases under the care of-Dn. 
Barlow and Sangster. The following case in an adult mxj, 
perhaps, be classed as an allied form of Erythema. It also 

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Erythema. Sl8 

throws light on the origin of certain forms of Melauodermia and 
Leacodermia. 

Cub. — Eliza B — , set. 83, lady's maid, of somewhat dark 
complexion, was sent up to me by Dr. Thos. Fagge, of Ascot, 
St the end of November, 1880. There was no history of affec- 
tions of the joints or the skin in the family. She herself bad 
Buffered from rheumatic fever at twelve years of age, and had 
since been liable to palpitation of the heart. 

Four years before I saw her, brownish red patches appeared 
on the abdomen. They itched, though not severely, and they 
have never entirely left her. Lately she has had a simikr rash 
upon her back. On admission to the hospital she presented 
a nearly uniform reddish eruption over the back, made up 
of more or less circular patches, very slightly elevated, 
smooth, and of a yellowish tinge, which does not disappear 
on presaore. There are no papules, no scales, and no well- 
formed wheals. On the abdomen the patches are more 
separate and gyrate in form, the inside being pale and the 
edge strongly pigmented. The eruption extends to the flanks, 
nates, thighs and shooldera, but the head, chest and Umbs are 
&ee. She says it itches, but there are no scratch marks. I 
had a watercolour drawing taken by Mr. Hurst, and after 
other means had been tried, found belladonna liniment suc- 
cessful in relieving the irritation. After eight weeks there was 
no other improvement. She was soon after attacked with 
rheumatism, recovered well under salicylate of soda,* but had 
a relapse, which detained her until the end of April, 1881. At 
that time the redness and irritation had disappeared, but the 
pigmentation remained. 



II, ECZEUA. 

Depmtionandvarietiea. — Excluding traumatic dermatitis, i.e. 
cases of eczematous ernptioa in which the lesion corresponds in 
eitent and in duration to the operation of an external irritant, 
we may perhaps usefully recognise the following as the most im- 
portant clinical varieties of "eczema," i.e. of common, idiopathic, 

' la thii patient, m in mnn^ other) taking MljcfUteB, I l|ar« loi^ad tbn urins 
Kdnce copper. -, , 

u,.,--,-.,,CTOOJ^If 



214 Obaervationi on Superficial Dermaiilit, 

superficial dermatitis, which has reached or will reach the sta^ 
of exadatioD. 

] . The most uumerouB and characteristic group of cues, 
those which may be called typical eczema. The patients miy 
he of either sex aod of any age, but are more ofteu young or 
middle aged adults than children or aged persouB. The erupti<m 
begins as a papular erythema, but the papules rapidly become 
small, thin walled, superficial vesicles, which so readily bant 
under friction that (although almost always present if looked 
for at the right timej they are in most cases practically sbsenL 
A weeping surface thus forms, over which the traces of vesicles 
may often be discerned {6tat ponctue). As the profuse secretion 
subsides, thin yellowish crusts appear, the dry surface becomes 
covered with small dingy scales, the redness and infiltration 
gradually subside, and the skin returns to its normal conditioD. 
Only rarely is accumulation of pigment observed, and never 
formation of scars. The course of the disease is more or less 
acute at the outset, but soon becomes chronic, and is apt to 
return after cure. The distribution is characteristically limited 
to the thin skin of the flexor surfaces, the favourite places being 
the bend of the elbows, the hams, and the back of the ears; next, 
the face, neck, arms and hands, axiUte and groins, abdomen snd 
genitals, thighs and legs ; while this form of eczema is rare on 
the scalp, buttocks and feet. Always more or less symmetrical, 
it is often as exactly so as psoriasis. Lastly, it is almost always 
accompanied with itching as well as smarting. 

With respect to the pathology of this commonest and most 
characteristic form of eczema, I confess that I am quite unable 
to recognise its association with any other disease, or with any 
supposed diathesis, constitution, dyscrasia, or temperament. It 
has, I believe, nothing to do either with rhenmatism (i.f. 
multiple synovitis with pyrexia) or with gout (arthritis with 
deposits of urates of soda), or with scrofula (caseous infiltration 
of lymph glands), or with rickets, or with anffimia, or with 
gastric or uterine disturbance. Ko doubt we see cases of 
eczema in conjunction with each of these conditions; if tbii 
never happened, we should have to investigate the reason of 
such mutual exclusion ; but I believe that it is essentially a 
disease of the skin and nothing else. As to the blood espe- 



Eczema. 215 

aaiij, we have not, bo far as I koow, the least reason to sappose 
that its cocditioa ia eczema differs from that of health. 

2. Umutrgal eczema. — ^This is a rare form of disease, and many 
of the Biippoaed cases of it are probsblj better described as 
exfoliatire dermatitis or pityriasis rubra. £ut a uaiversal, 
common saperficial dermatitis may occur, which by its locali- 
utiou (when it first appears or after it has become chronic), 
by its return as a less general affection, or by other characters, 
cisims the title of genuine eczema. 

Casb. — Alexander It — , set. 14, came among my ont- 
pfttients towards the end of 1877 with inveterate and nni- 
Terul eczema. It was clear that he could not have the 
necessary attention at home, and I therefore took him into 
the hospital. He was a thin, miserable lad, of naturally 
dtrk complexion; and his whole body had acquired the 
colour of a mulatto by the gradual increase of pigment. 
His father and mother and their other children were of 
ordinary colonr and had healthy skins. It appears that he 
vss a healthy baby, but at fire years old began to safTer from 
" scald head." This gradually spread over his body, and though 
often better and worse has never left him for nine years. On 
■dmission, there was dry scaly eczema of the head, face and 
neck ; the ears were fissured and blood-staioed, as was the right 
sulla. The eruption on the arms and back was papular; on 
the abdomen, genitals, perineeum, nates, and thighs, red and 
profusely weeping. Except the palms, soles, and part of one 
shanlder, there was no part of the body free from the disease. 
The viscera were normal, the urine free from albumen, and the 
appetite good. Under ordinary local treatment and steadily 
increased doses of arsenic, in spite of occasioaal interruption 
from sickness, the disease rapidly improved, and after five weeks 
the lad went out with an almost healthy skin. He has several 
times shown himself again when there has been a slight return 
of eczema of the scalp or ears, but in other respects he con- 
tinues well, and faas grown into a stout healthy ladj the whole 
skin continues remarkably dark, but is smooth, soft, and in 
every other respect normal. 

S. Impetigo. — The pustular form of common superficial der- 
matitis as it affects the scalp or face of children is very charac- 
teristic and well known. It includes the " scald head," achor or 



„Gooj^lf 



216 Obiervaiions an St^erficial Dermatitu. 

Crutia lactea of older writers, Willan's Porrigo larvaits and 
also P. favosa, the Impetigo larvalia of BatemaD, Tagne 
muqaease, Eczema impetigo. 

It rarely affecta infants before the scalp is well covered with 
hair, and still more rarely adults, although we have lately had 
several cases of typical impetigo of the scalp in both men and 
women. The exudation is not the characteristic albuminous 
secretion of eczema, but is purulent, forming thick massive 
crusts. The eruption is in patches ; it is accompanied by com- 
paratively little itching ; instead of afTecting the earSj limbs, 
and bend of the joints, it is at iirst confined to the scalp or 
face, especially the lips and nose, and when it spreads elsewhere 
appears to do so by direct inoculation. The three conditions 
to be distinguished from this true idiopathic pustular derma- 
titis, are, (1) the pustular inflammation of the occiput caused by 
pediculi, almost exclusively confined to children, and readily 
cared by removing the irritant; (2) scabies, which may be little 
developed on the feet or hands or nates, or may even have been 
cured and yet has by inoculation of its pus produced " impe- 
tigo " of the face or scalp of the child j (8) true ringworm, 
either obscured by the inflammation it produces, or more often 
concealed or even supplanted by the severity of the applications 
which have been used to destroy the fungus. 

That impetigo of the scalp and face in children is really a pus- 
tular form of eczema is proved, by an ordinary eczema of the scalp 
or face in an infant becoming pustular and crusted as the patient 
grows older, by impetigo in a child assuming the characters of 
common eczema when it recurs, and by impetigo of the scalp 
being associated in the same patient with vesicular or weeping 
eczema of other parts. We may connect its pecularities, first, 
with the age of the patient. The skin of children appears to be 
more prone to suppurate than that of adults. Not only eczema 
but scabies is more often pustular with them ; and the scattered 
pustules of doubtful origin which go by the names of ecthyma 
and impetigo sparsa are almost confined to children. Secondly, 
the presence of large and numerous sebaceous glands seems to 
lead to suppuration, when the surface is infiamed. We know 
how readily pustules form within the nostrils and in the eyelids 
(hordeolum), over the shoulders, on the face (acne), and in the 
beard (sycosis). When eceema spreads to the head in adolta 

. „ Google 



Eczema. 217 

we occasionally see a trae impetigo resultj but I have never 
seen pustular eczema on a bald headj here it produces its 
ordinary clear secretion. Moreover, impetigo is seldom seen 
on the downy scalp of an infant. 

4. Eczema of the lipt. — This is a carious and somewhat rare 
form of superficial dermatitis, which used to be called psoriasis 
labiomm. Its true nature is shown by sero-parulent secretion 
being present, though in small quantity and forming very tbio 
Kabs, and by its association with eczema elsewhere, espe- 
cially with impetigo of the face. Thus, a little boy with this 
sSectioD in its most marked form, had also a few puatalea on 
the scalp and ordinary eczema of one ham. Its peculiar 
appearance is dne to the thinness of the skin of the prolabium 
leading to hsemorrbage, so that the crusts are brown or 
black and massive. It sometimes affects the lower lip alone, ' 
AH the cases I have seen have been in children or young girls. 
The treatment I have foond snccessfol is removal of the cmsta 
with bread poultices and application of our Unguentum metal- 
lorum.i The patients are often pale and are benefited by steel. 

5. Eczema rimosum, mbrum, sqnamosnm, of the hands, 
including the so-called grocer's and baker's itch, and most 
cases of what has been called psoriasie palmaris. I have seen 
two or three cases of true psoriasis of the palms asso- 
ciated with ordinary unmistakable psoriasis, but I believe it 
never occurs independently. Such cases are either typhtlU 
iquamoia of the palms and soles, with its small, scanty, dirty 
scales, its dry surface, its symmetry, and its predilection for 
the inner side of the sole ; or else they are true eczema in its 
sqi^mooB stage. 

6. Ecsema of the anus, perineeum, vulva, or male genitals, 
extremely irritable, weeping, very rarely pustular, 

7. Eczema of the outside of the forearm and legs. A form 
not uncommon in adults, usually rather acute in its onset, 
spearing in separate round patches, sometimes vesicular, more 
often presenting the appearance due to broken vesicles, which 
was described fay Devei^e as itat ponclu^. Sometimes spread- 
ing to the thigh and upper arm, but rarely to the hand or foot j 
ind rather avoiding the oaual position of eczema at tbe elbow 
mi ham. 

■ COotaimng «qaA^ pait« «f Ung. ilioci, Va%, PlamV A|Xt., ui4 Un^. ^jix, mt, 



218 ObtervaHont on Stiperficiat Dermatitia, 

8. Eczema or dermatitis intertrigo, always weeping and 
painful, characteristically affecting the folds of the neck in 
infants, the mammte in women, the nates, the thigh and scrotnm, 
the groins, and occasionally the toes, I have never seen it on 
the eyelids or between the fingers. 

9. Eczema or dermatitis of one or both legs abore the ankle, 
depending on venons delay, weeping and conflaent, oedematous, 
very chronic, rarely seen before middle age, and often combined 
with varicose ulcers. 

10. The v^ chronic pniriginons ecaema seen in old persons ; 
the lesions usually papular or scaly, with little moisture. To 
thia group belong the worst cases of eczema genitalinm and 
eczema podicis. 

11. Chronic, dry, "single-patch" eczema, not itching and 
lasting for years unaltered. In a patient now under my care, 
a man of sixty-five, such a patch appeared at forty on the 
inside of the left thigh, lasted upwards of twenty years without 
any change, then disappeared, and has for the last eighteen 
months been succeeded by a similar dry non-irritable patch, as 
large as a crown piece, on the inside of the right forearm. The 
old iplace was called psoriasis, probably incorrectly ; this one, 
whidi he tells me is just like it, is undoubted eczema, with 
abortive vesicles. The patient is a hearty man, who has lived 
freely, hut never safi'ered irom gout or anythii^ like gont or 
rheumatism. 

12. Lichen tropicut, the acute, intensely irritable, papular, 
and almost universal "prickly heat" of the tropics, I have 
lately had two well-marked examples of this curious affection 
under treatment. 

Cabs. — The patient is a remarkably tall, well built man of 
thirty. He was for several years a soldier in the East Indies and 
was then attacked by this disease. He drank freely, but could 
not connect the outbreak with a particular debauch nor with any 
other exciting cause. He has been home some months, and is 
still much troubled with what is now a very irritable papular 
ecEema. The parts affected are the abdomen, groins, and 
buttocks ; the perinseum and genitals are free. There are also 
a few scattered papules on the foreanns and on both thighs. 
The irritation continues great, as is testified by numerous 
scratch marks, but it does not give rise to urticaria. Under 



Scxemi. 219 

abatinence firom drink, free diluents and lazatire medicine, he 
soon improved. The local treatment we found best was an 
oiatment of one drachm of boracic acid made np with equal 
weights of white wax and lard, aoftened with oil of almonds. 
It happened that one of the gentlemen present when this 
patient appeared had been in Bombay, and another in Aoatralia, 
and both recognised thia affection as the prickly heat with 
which they were familiar. 

Casb. — ^A soldier, st. 27, came to me with a papular and 
pustular eruption distributed over the trunk and limbs ; most 
severe on the abdomen, buttocks, and thighs. The head, face 
and neck, the hands and feet, and the genitals are quite free. 
It is very irritable and there are numerous scratch marks. The 
general aspect is more like prurigo than ordinary eczema. 
There are some erythematous patches with small wheaU from 
scratching. He says that he had the eruption when he first 
went to Bengal in 1878. It disappeared in the cold season but 
returned with the heats. He got rid of it during his voyage 
home in December, 1880, hut it has reappeared this spring. 

These are the clinical varieties of eczema which seem to me 
to be most worth recognising for the practical purposes of dia- 
gnosis aud treatment. They are v^eties, not separate diseases, 
esch of the local kinds being liable to spread into the more 
common and generalised eruption, and each of the pathological 
species being liable to assume one of the allied forms. They are 
all common inflammations, t. e. such as can be produced at will 
by an irritant; all niperfioial, not deeper than the papillee, and 
therefore, however severe, never followed by scars ; all " moitt 
Mtert," i.e. the inflammation is severe enough to cause at one 
period or other a visible exudation, presenting according to the 
stage and locality an injected surface, papules, vesicles, raw weep- 
ing surfaces, cracks or fiasurea, puatulea, scabs or crusts, a dry, 
red surface, or branny desquamation. But we never see produced 
the imbricated scales of psoriaais, nor the large grouped vesicles 
of zona, nor the rings of tinea, nor the bullie of pemphigus, 
nor the large, thin, adherent plaques of exfoliative dermatitis, 
Dor the polymorphic leaions of syphilis. Lastly, all these 
varieties of ecz^na are more or less accurately symmetrical, 
mote or less irritable, and run a chronic course, with great 
liabiUty to relapse. 

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S20 Observations on Superficial Dermatitis. 

etiology. — On the oae baud, we must never lose sight of 
the fact that eczema is aDatomically a " common " superficial 
dermatitia. For couveiiience we restrict the name to one 
which has reached the stage of visible liquid exudation. 
The exudation may be plasma with but few leucocytes and 
little fibrinogeuj the non-coagulable lymph or "serum" of 
the older writers, consisting almost entirely of the water, 
salts, and albumen of the blood : we then have the typical 
vesicular or weeping eczema; the dischai^e is abundant, 
watery, irritating from its saline character, and characteris- 
tically stiffening linen from its albumen — insiar teminis, 
like white of egg, comme les tirops. Or the exudation may 
be richer in leucocytes than the liquor sanguinis, and these 
rapidly dying and undergoing fatty degeneration form the 
opaque, yellowish, milk-like lymph known as pus. But essen* 
tially the inflammation is the same, and we see it in all its 
forms and stages, not only in the various kiods of eczema enu- 
merated above, but also in scabies, which, though rightly dis- 
tinguished clinically, is nothing but a commoo dermatitis set 
up by a special irritant, the eczema of the acarus, or, as Hebra 
called it, " Scabies eczema." 

On the other hand, we must recognise something besides 
an irritant, namely, an irritable skin. Often none but the 
ordinary conditions of the skin as to heat, moisture, cold, 
and friction can be discovered. Even when we can recog- 
nise an exciting cause, as in eczema solare, or in scabies 
itself, we see that the guidguid irritabite, as well as the quidquid 
irrilans, is necessary ; for two men may be equally exposed to 
the Bun yet only one will be sunburnt; two women may be 
washing at the same tub, but only one has chapped hands; two 
children are infested by itch-mites, yet one has only the bur- 
rows to show and slight local irritation to complain of, while the 
other is covered with pustules, scabs, and blisters, over regions 
which the acarus never visits.' 

Now, what is this guidguid irritabile which makes an eczema 
of a traumatic dermatitis ? It is not the normal skin, or we 

> As ID ■ cue of Hvere bullong icabies, affecting the face ai well a« Ihe tmiik 
and limb* of « little boy. ' Ony's Hoijiital ReportB,' Scries III, Vol. Jili, p. IM, 



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Eczema. 321 

should all have eczema from the friction of our clothes and the 
irritation of soap and water. 

It is not "dyacrasia" of the blood or any other " bamoar," 
for there is not even a pretence to prore that the btood of ecze- 
matoas persons differs from that of others. 

It is not a poison, an " acridity " circulatiDg in the blood, 
for why should it affect the skin, and certain parts of the skin 
only, while the more tender conjunctiva and the more vascular 
mnooQB membranes escape ? Moreover, in syphilis, where really 
an infective something is conveyed by the lymph and blood- 
stream to the skin, the lesions there produced are anything 
except ecEema. When other irritants are carried to the skin 
— iodides, bromides, belladonna, copaibaj &c. — they produce 
rashes which simulate, we may almost ssy which are, acne, ery- 
thema, ecthyma, but never what could be mistaken for eczema. 

It is not " defective innervation," for if the central nervons 
system is at fault, why have we no evidence of the brain or 
spinal cord being affected ? If a reflex paresis is set up, what is 
the seat of the primary irritation ? If the fault is in the peri- 
pheral nerves, then it is after all a mere local affection of the 
skin. Besides, we know that in the cases best CBtablished of 
lesioDB due to injuries of trophic nerves, sloughing of the cornea 
after division of the fifth, wasting of muscles in amyotrophic 
lesions of the anterior coroua of the cord, Mr. Hilton's case of 
ulcer of the finger from pressure on the ulnar nerve,' the glossy 
tkin after injury to nerve trunks/ in all these and other more 
donbtful instances we find either gangrene or atrophy, not 
eczema, as the result of "defective innervation." But, more 
important still, we have in zona an affection of the skin 
which is inflammatory, and which ts also clearly connected, 
by its distribution, by the neuralgia which accompaoies or 
follows or occasionally precedes it, and by direct anatomical 
post-mortem evidence, with a lesion of the ganglia of cutaneous 
Derves. Yet zona is not eczema. 

It is not a general " constitution " of the body nor a 
" diathesis " or disposition of the organism ; for we see eczema 

' See Hr. Jacobtoo'i Edition of ■ Hilton on Bert *ni Fain,' 8rd edilion, 
p. 200. • . 

■ Id cbh* of gUDthot wonadi in the AmericsQ Civil War repotted l>7 Surgeon 



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223 Obtervationi on Superficial Dermaiitit. 

ID persons of all ages, of botli sexes, of all races, weak and 
strong, thin and fat, pale and Toej, dyspeptic and robiiBt, gouty 
and free from gout. 

As to the existence of a herpetic diathesis I shall have to 
speak presently, when discussing the stiology of psoriasia. 
But even granting that there is such a thing, we find no 
practical agreement among its most eminent supporters as 
to its limits or its signs. While Prof. Hardy and most of 
his disciples regard eczema as " I'expression type de I'herp^ 
tiame," and only admit in addition lichen, psoriasis, and 
pityriasis, others, like M. Oigot^Suard, of Cauterets, include 
under " manifestations primordiales de I'herp^tisme " (beside 
all forms of eczema and impetigo, psoriasis, lichen and pem- 
phigus) acne rosacea, prurigo, urticaria, pityriasis, fiirun- 
colus, and many more; under Herp^tidet mtiqveutet, most 
internal diseases; and as "manifestations ultimes de I'herp^ 
tisme," consumption and cancer. 

M. Bazin, again, distinguishes between herp^tisme (the 
dartrous diathesis] and arthritisme (the gouty and rheumatic 
diathesis), and classifies the varieties of eczema according to 
their setiology as traumatic, scrofulous, herpetic or arthritic. 
" L'eczAtte n'exiate piu comme entiti morbide, C'ett une affec- 
tion g^n^rique apparienant i I'ordre dea vSticvles que '/'on 
retrouve dans phuieura maladiet dont elle ne doit iire considere'e 
gtie comme la manifeMtation.^ The following are the characters 
by which herpetic may, according to M, Bazin, be distinguished 
from arthritic eczema : 

Ecz^a herpStique. Ecz4ma arthritique. 

Spreads. Circumscribed patches. 

Limbs chiefly affected. Uncovered parts or mucous 

orifices. 
Symmetry. No symmetry, 

^ee secretion. Dry, or scanty secretion. 

Bright red. Deep venous red. 

Frequent recurrence. Persistent. 

Itching. Smarting. 

Frequent metastases. No metastases, but previous 

affections of the joints. 
■ Buin, ' EiuMU CtiUqao,' pi 76. 



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Bezema. 228 

Now, the second columa seems to describe the local chronic 
pnui^noiu eczema of the anus and vulva, the first common 
ecKma; but I venture to think that itching is more severe in 
locil drcomscribed eczema than in ordinary weeping eczema 
of the face or limbs. As to " metastases " I aappose few 
pathologists believe in tbem, but if ever they occur it is rather 
in the ohronic dry eczema of the aged than in the acate moist 
tetter of the young. 

Instead of saying dry eczema means arthrite, wet eczema 
means dartre, and pustolar eczema means acrofuHde, when each 
of these words is so vagae and elastic that the assertion is 
almost as hard to disprove as to prove, sorely what facts warrant 
D§ in saying is that pustular dermatitis is more- Irequent on 
the &ce and scalp, and profuse secretion on the thin skin of 
the flexures ; that impetigo is commoner with children, and 
dry chronic eczema witb persons past tbeir prime. 

When eczema occurs in a thin, pale child, whether with 
caseons lymph glands or no, we all agree in giving steel and 
cod-liver oil ; when it occurs in a person who has had gout we 
prescribe colchicnm; and when it occurs io a person who bears 
traces of malaria we add quinine to local treatment, but beyond 
these limits I do not think that an unprejudiced judgment 
can' at present go. Most cases of eczema are idiopathic, 
neither traumatic or " diathetic," and we cure them best by 
local treatment. 

Though believing that the true line of progresH in dermatology 
was from Willan to Hebra, and that the fancies of Alibert have 
been purely mischievous, I do not deny the services of his 
BQccesBora at St. Louis, and especially of &1. Hardy. The 
advance which we owe Biett in recognising the group of 
t^hUida is most important and tfae letiological classification 
which we are now discussing is the ultimate one and the most 
practically useful of all. But we must follow only proved facts 
and distnut the guidance of ill-deSned terms which are them- 
selves the Burvivals of systems long proved false. 

X admit that the question is much altered in the hands of 
one who is not a specialist, bat a sound pathologist as well as an 
eminent surgeon. Mr. Hutchinson would associate together as 
"dartres," diseases which are characterised by relapsing, by 
tymmetry, by cbronio and obstinate course, and by distribution 



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234 ObBtrvationt oh Svperfiaal DermatUu, 

on circumscribed patches rather than diCTusely. We are uked to 
believe that these diseases are due to sotne unknovn cohBtitn- 
tional condition which may be called the dartroua diathesis. The 
diseases so classed by Mr. Hutchinson are psoriasis, pemphi^i, 
man; cases of ecsema, and a few of lichen, with certain forms 
of lupns. This list differs from M. Bazin'a and from M. 
Hardy's. If such a clioicat group is to be made I shonld be 
inclined to add prurigo and pityriasis rubra. But, while recog- 
nising certain likenesses between each, each also differs from the 
rest, and resembles some other affection, I should prefer to 
admit that all these diseases approach more or less near to 
psoriasis, but of this I shall presently have to add a few words. 
With regard to eczema I will only say, that while some chronic 
dry forma come near to lichen, prurigo, and psoriasis, and some 
acute and generalised forms approach exfoliative dermstitit 
and pemphigus foliaceus, the ordinary moist tetter shows rather 
contrast than likeness to psoriasis, the pustular form differs ia 
almost every point from the " dartres," and some chronic cases 
of eczema simulate lupns, or elephantiasis, as closely as others 
do its supposed herpetic allies. 

Treatment. — With respect to treatment of the varioos forms 
of ecEema I have enumerated, the first condition of success is 
I believe to recognise that the conditiou is one of ordinary 
inflammatioQ of the Malpighian and papillary layers of the 
skin, not " eonstitntional " or " diathetic," any more than 
inflammation of the kidneys or of the stomach. 

Next, we must look carefully for sources of irritation. It is 
remarkable that ordinary squalor and neglect produce pustalai 
eruptions, but seldom true eczema ; and vermin lead to prurigo 
or to urticaria^ but seldom to eczema. Nor is eczema pro> 
dnced by animal poisons, as are the pustular and erythematous 
eruptions which we see in the hide workers of Bermondsey, 
and in butchers. Eczema is the result of the irritation of 
sweat or of friction, or of exposure to fire, to hot sun, or cold 
wind. Still more frequently it is produced by the mechsmcal 
or chemical irritants used in various trades ; as the water ia 
which the washerwoman's hands are kept half wet and half 
dried, and the coarser kinds of sugar handled by grocers. 
Eczema of the anus and genitals again may sometimes be 



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Eczema. 235 

traced to want of HcmpoloaB cleanliness in adults as well as ia 
chiJdreD. 

We must also, in all cases of pustular dermatitis, remember 
the conta^ous property of pus, varjing greatly in degree, bnt 
never to be lost sight of. Many cases of impetigo which seem 
at first sight to be idiopathic^ can be traced, especially in 
children, to inocnlation by the nails from a few pustules pro- 
daced by scratching an ocdpat infected with pedicoli, or to 
similar inocnlation bom a whitlow, from an inflamed phimosis, 
or &om the sores produced by accidental injuries. The spread 
of scabies itself is not only due to the direct irritation of the 
acams and the secondary initation of the patieafs nuls, but 
kIso to the contagion of the pus. So, again, we see fumocnli 
and ecthyma appear in crops ^m a single primary source of 
suppuration. 

In moat cases, however, and particularly those of the most 
typical kinds of eczema, we find no traumatic or infective 
origin. They are strictly idiopathic. Between the purely 
accidental dermatitis, to which all skins are liable under irrita- 
tion, and the purely idiopathic eczema where oo irritating 
condition can be found, there is every gradation. As in 
catarrhal pneumonia, as in dyspepsia, it commonly takes two to 
make a qoarrel. Some persons are exposed to cold yet do not 
coogfa, others eat too much and too fast yet suffer no remorse. 
All I ventore to maintain is that the ^fierence between one 
person and another is not in the " constitution " or " diathesis," 
bnt in the anatomical structure (hereditary or otherwise 
acquired] of the longs, or of the stomach, or of the skin. 

We mtut then, regarding eczema as dermatitis, treat it like 
other inflammations, and first and most important is local 
treatment. 

We relieve the inflamed skin from the friction of the clothes 
and as much aa possible ftvm that of movement. We protect 
it from air by rags soaked in lotion, or by smearing it with 
unguent, or by dusting it with an indifferent powder. And 
thirdly, we must protect it from water, or rather Arom the 
change from moist to dry by evaporation, which ia the result of 
washing. 

The late Professor Hebra published not long before his death 
a characteristic and amusing lecture on the deleterious effects 

VOL. XXV. ^^ • ^ 

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2S6 Obtervationa on Sh^eriiaal I>ermatiti». 

of water upon the tkm.^ Vvw of ub etsn. be Donviiuwd tint the 
daily tab will do healthy English skiiu anything but good. 
But there is no doubt that not only soap and water but water 
alone may be an irritant to an inflamed ikin, just aa food 
which ii auitable to the atomach in health may be an imtant 
in gastritii. If we keep an eczematoni aur&ce under water, it 
is aoothing to long aa the temperatnre ia the tame : a eoo- 
tinuoua bath is sometimes excellent treatment, and there is 
no olgection to the water dressing except from the Iteat it 
maintains. But we shall do wisely to forbid waahing in the 
ordinary way in most oases of eciema. Oatoieal, c» gneU or 
sise baths are soothing as well as cleansing if of pr^er ton- 
peratore (about 90° F.)> and if continued for at least a qnsrter 
of an hour ; but they are more nsefnl in cases of prurigo, espe- 
cially infantile prurigo, than in ecsema, and should only be 
used in this disease when the snrfisce afibcted is la^e and the 
secretion free. In ecaema, and especially in Impetigo of the 
scalp, the hair must of course be cut short, or in serere eases 
shaved, the omsts softened with poultices and pre¥anted from 
re>forming by oil, and the scalp kept clean with equal parts (tf 
strained white of egg and water ; even this should be sparing 
applied and aompulously dried. 

What we want to procure is uniformity of condition. AH 
irritants to living tissues, mechanical, chemical, or what not, 
are more or less sudden changes. It is possible to heat a 
frog's muscle until the myosin is coagulated without producing 
a twitch, or to introduce a constant voUaie current into a 
nerve, gradually to increase its strength nntil it much exceeds 
that of an efficient stimulus, and gradually to diminish it until 
it can be withdrawn altogether, yet without a negatiTe varia- 
tion being produced. It is the rapidity of a change, not its 
amount which acta as an irritant, whether in the nonnal or the 
morbid department of physiology. 

Foultieea oi water dressing with gutta percha or india 
rubber or goldbeater's skin are almost always hortfol tnm the 
heat which is produced, whether first applied oold or hot. Nor 
do I think that we gain by using alkaline water, as used to be 
the custom at St. Louis. Theoretically, one would reoonmeod 
"the normal salt solution" of the labofatory with eno«^ 
■ TniuUtod in th* 'Londm Mcdieil Btmwd'for HsKk 15, ISTT. 

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Eczema. 227 

cuboBBte of Kxia to make it faintly alkaline. But, practically, 
it IB difficult to prevent even half per cent, alkaline BolutiouB 
from caosing irritation to a raw ectematous surface. Except aa 
prolonged baths or in exceptional ciroumBtancea, it ia better, I 
believe, to use moist applications in eczema only as medicated 
lotions. 

Before leaving the subject of water in eczema I may remind 
the less experienced reader that the cases of general, irritable, 
weeping ecsema are, in old persons, and occasionally in infants, 
btal. In these cases contianous lake-warm baths seem to be 
indicated, bnt whether really " exhausting " or not, they are 
mpposed to be so, and must therefore be administered with 
caation. One of my first cases of ecsema was in s stout, hand- 
some, healthy old gentleman, with pink skin and silvery hair, 
whom I saw with Mr. L — . It was widely disbrtbuted and 
excessively irritable. Fresh from Vienna, I ordered a eon- 
tiuDouB bath, as I had seen it used by Hebra. Great relief 
Mowed; but an older and more sagacious physician, who was 
afterwards called in, while not attempting to core the eczema, 
predicted a speedy and fatal result, which soon after happened, 
and I have not met Mr. L — since. 

A short time afterwards, when medical registrar in this 
hosptal, I found, just admitted under Dr. Wilks's care, a 
patient with extensive and irritable and weeping eczema, also 
a nun above aeven^, with clear pink complexion and abundant 
white hair, aud also with a history of gout, though, as in the 
other case, without evidence of renal disease. I made an 
uu&vorable prognouB of the case. But the patient recovered. 
I have at the present time an old gentleman of eighty uudn 
treatment with extremely obstinate pruriginous eczema, and 
he appears at present to be equally unlikely to part with his 
enema or with his life. 

The drugs which we find most useful in controlling local 
inflsnuuation are those which belong to the group of astrin- 
gents — zinc, boras, alum, chalk, tannic acid, silver, load. Of 
these lead is the most generally and deservedly employed in the 
treatment of eczema. Zinc and borax appear to have the 
spedal additional merit of d''"'"i"t''"g irritation. Nitrate of 
^vei is only suited to circumacribed and chronic patches of 

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228 ObtervationM on Superfieial DermatUw. 

We bare three modes of applying theae drags, as dry 
powders, in aolntioa, and in Baspenaioa or chemical combina- 
tion as UDguenta, oleates, or plasters. The general role I 
learned from the late Dr. Haghes Bennett is an excellent one : 
lotions to wet and ointmenta to dry emptions. If greasy 
applications are made to a profusely secreting Eczema imi(&> 
dmu the discbai^ washes away the ointment^ so that the lead 
or chalk or sine never reaches the diseased surface any more than 
if it were applied over the thick cmats of Impetigo larvata. 
On the other hand, if lotions are placed in contact with intact 
epidermis, the homy scales, rendered more water tight by the 
sebum which coTers the surEace of the healthy skin, form an 
limoat impenetrable barrier to the action of the drug in 
solution. 

There are, however, exceptions to the rule. Lead lotion ia 
often found to be the beat application in the early stages of 
eczema while still erythematooa and in some of its most pruri- 
ginous dry forms. Lotiona are indicated in hot veather when 
the skin sweats freely, and ointmenta in winter when there 
is no fear of their turning rancid. Lotiona are easily applied 
to infants by the nurse, uid to the face and upper extre- 
mities by the patient himself; hut to he efficient they must be 
constantly renewed and the surface aa lightly covered as 
possible. Hence they are less applicable to parts of the body 
which cannot readily be exposed and handled. For the same 
reason one more often prescribes ointmenta as a vehicle with 
hospital out-patients, and those who are about all day, and lotiona 
with in-patients, and those who can or must lie up at home and 
devote themselves to their cure. Lastly, we meet with certain 
cases io which our patients assure us that either lotions or oint- 
ments always disagree with them, and I have too often verified 
this assertion to neglect it. 
When there ia much clear serous effusion, and especially in 
s folds of the limbs, powders are often better than 
B or unguents. Finely powdered chalk, oxide of 
and starch, dry up such weeping surfaces and fimn 
under which the healing process goes rapidly on. 
p of-infaots and of the breasts in women is often 
red by first cleanung with white of ^g, carefully 
:ben powdering with oxide of zinc. This plan is, 

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Eczema. 229 

liowerer, ill adapted when tike affected parts are allowed to be 
in motioD, as irith intertrigo of the nates. In sncb cases the 
ordinary beuzoated zinc ointment, irith doable the officinal 
quantity of zinc oxide so as to make it drier and firmer, or 
vaseline -with sine, are better applications : they should be 
Bpread upon thin rags and kept in place with a suspensory 
bandage between the thighs. When a similar condition arises 
from riding or rowing, the interval between the periods of 
irritation are longer, and it is possible, by scmpulous cleanli- 
ness and diligent powdering, to procure healing without alto- 
gether stopping the canse. 

There are, however, some cases of eczema, especially, I think, 
in the young, and of the moister kinds, which resent erery kind 
t r medicalion, and can only be treated by the sedulous employ- 
ment of the most soothing and indifferent applications. Among 
these, as I have already pointed out, water cannot be reckoned; 
it almost always does harm, and alkaline washes are worse. 
Thin size, cwld cream or vaseline, I think, are the most likely 
to succeed in such cases. Olycerine of starch occasionally 
tncoeeds when everything else seems to fail, but it often proves 
extremely irritating, and on the whole is I believe less used 
than it was some years ago. Glycerine has the advantage of 
mixing freely with water and may thus be used as a vehicle of 
tannin or of borax to moist surfaces and mucous membranes; 
hut the withdrawal of water from the surface appears in itself 
to be Bometinies an irritant. 

I am convinced that for the common " eczema solare " of 
Snitserland and of the sea glycerine ia with most persons of 
little or no use, and is far better replaced by vaseline, which 
should be gently rubbed in before the face begins to sweat, 
and renewed from time to time while the exposure continues. 

After the acute stage of an eczema has passed, and it is as a 
chronic inflammation that it usually comes before us, astrin- 
gents are still indicated, bat instead of soothing and protection 
some Htimulation is necessary. This we obtain by adding a 
tnercnrial salt, and the Ung. Melallomm of our Guy's Pharma- 
copoeia is one of the best combinations for treating impetigo 
and chronic eczema. The red^oxide ointment, either alone or 
added to Ung. Zinci, ia also very valuable, especially in the 
moat chronic and indolent forms which approach ulceration, 

, Gooj^lf 



230 Obtervatiofu on SttperfiettU DermatUu, 

In obfltinate ecsema, especially vhere of small extent and moist, 
the application of Liquor Fotassse, as advised by Dr. McCall 
Aoderson, is often an efficient and rapid means of cnre. Aad 
nitrate of mercory is the best application for local deep finurei 
of inreterate eczema rimosam. In the very chronic ecsema, 
which is dry and scaly without much active infiammation ud 
itching, tar ointment, or our Ung. lAq. Carbonit detergaUit ue 
indicated. For single patch eczema, if wet, Liq. Pottuta, if 
dry, Ung. Pici* ligttida ii best. 

Meantime we must prevent the irritation of aeratcbing and 
rubbing by relieving its cause. Oxide of line, calamine, oi 
borax, as ointments, weak corrosive sublimate wash ot Vug. 
Hydrargyri ammoniati, hydrocyanic acid lotion (5iv — jvj to a 
pint), cyanide of potassium ointment (gr. ij to the ounce], and 
mere protection from the air by such indifferent applications si 
cold cream and vaseline : — these are all useful for the purpou 
indicated, the poisonous sedative being used with caution when 
the moist surface is extensive. One advantage of the continnons 
bath is the relief from itching it affords. But beside external 
remedies it is important, especially with children, to add sedativa 
to secure rest for the inflamed skin at night. Opiates are 
undesirable not only on general gromids for children, but also 
because they occasionally a^[ravate pruritus. Henbane is 
better, and combined with camphor as a pill or a draught 
often seems to suit old men better than any other hypnotib 
Chloral hydrate is particularly adapted to children, and is best 
given to infants alone. With older children and adults, bromide 
of potassium and chloral hydrate make the best combination. 

In obstinate cases of eczema of the hands the following 
method is almost always successful. Wash them thoroughly, 
removing all crusts, secretion, and dead epidermis, and euttiiig 
the nails short. Then rub vaseline gently in all over, pnt on « 
well fitting pair of kid gloves and keep them on night and day, 
only removing them for applying fresb vaseline. 

But with all our care we find local remedies inadeqoate to 
the cure of perhaps half our cases of eoiema. Even at Vienna 
medicines are taken internally in this disease. 

Impetigo rarely needs physic, but when the child is pale 
steel certainly hastens the cure, beside doing good otherwise. 
Steel wine for infants, the saccharine carbonate of iron for older 

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Begema. 231 

children, uid the ritnte of iron and quinine are all naefiil in the 
tnatmmt of children'! enema ; bat when they fail, and ateel is 
itiU indicated) it ii worth giving the tincture of the perohloride 
in glyeerioe and water before trying arBenic. In the WTera 
form of ehronie ecsema in children, eipeeially when not pna- 
tnlar and when widely diatribnted, arsenic it almost always 
necessary, and rarely fails of success. It must, of course, be 
b^on in small doses, and must always be given with food, and 
then it scarcely erer disagrees. Children bear it rery well eren 
in fnll doses, and grow fat and rosy while taking it. I hare 
pven as mach as fifteen drops of Fowler's sedation three times 
a day to a child of seven years old without any but good 
eBhcts. Sometimes the soda agrees better than the potash salt 
audit should always be well diluted i^ith water. Except a little 
symp to sweeten it no adjuvant is needed, Perseveranoe in 
tliia treatment is rewarded in the most inveterate caaes. I 
have given the above in a case of universal eczema which 
existed from infancy till near puberty in a boy, and was cured 
at lut in a few weeks by lednloos local treatment and persistent 
eibibitiou of arsenic notwithstanding sickness. I had equal 
SHcesB with a girl of sixteen, who had been subject to eaema 
from early ohildhoodt and suffered terribly from its excessive 
irritability and its deformity. She could never go out without 
s thick veil, and every evening was obliged to retire to her bed- 
room on account of the itching, which then became intolerable. 
Under amenical treatment the disease completely disappeared, 
sod she is now able to go into society. This case was one of 
those which were once explained by the theory of " metastaais," 
far when the ecsema was least troublesome the patient was 
Mbject to aathma, and this disappeared in spring and autnmn, 
tthsa the ecaema became most severe. Since, faoweverj the 
■km haa become normal the cough and dyspnoea have also 



In aonie children with more or less obvious signs of tubercle 
in t^ lymph glands or elsewhere, the exhibition of cod-liver 
oil certainly appears to hasten the core of ecaena, as well as to 
impnne their general health. 

I have already referred to the importance of hypnotics in 
^ treatment of irritable ecaema in children. 

In the acnte weeping eczema of adults experience confirms 

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282 Obtervatioiu on St^erficiat Dermatitit, 

the practice of giving saline laxatives along with local trest- 
ment. Friedricbshall or Carkbad water, Epsom aalts, and tbe 
"white mixture" of magnesia and sulphate of ma^esia, o> 
carbonate of soda with sulphate of soda and sulphate of 
magnesia, are the best kinds of purgatives. Occasionally sods 
and rhubarb succeed better. In the eczema of children fe« 
internal remedies are so useful as Gregory's powder. Tbe 
valne of mercury internally administered is almost confined to 
the disease in young children, and in some cases we cannot 
doubt its benefit. The caibonate of soda three psrts with 
Hyd, c. Cret& one part of oar pharmacopoeia is the best fwm 
in which to give it. 

Iron is seldom needed unless obvious aueemia is present 
But with women, especially towards the menopause, sulphite 
of iron with sulphate of magnesia forms an excellent combiiia- 
tion, especially if a few drops of dilute solpbuiio add be 
added. 

In the irritable and obstiuate eczema of elderly persons 
arsenic often appears to aggravate the malady. Local treat- 
ment assisted by internal sedatives is in these eases most 
useful, but occasionally purges appear to be of service, and 
certainly add to the physical and mental comfort of the 
patient. I believe that eczema occurs more often in conuec- 
tion with gont than does psoriasis or any other disease of the 
skin. In such cases colchicum is nudonbtedly indicated. 

The local persistent forms of eczema rarely benefit except by 
careful and persevering local treatment j but in the ordinsry 
chronic dermatitis of the legs in elderly persons laxatives are 
no doubt a valuable adjunct to elevation of the limb, and siti- 
ficial support of the enfeebled veins by flannel rollers, eUitic 
stockings, or, best of all, by Martin's india-rubber bandage. 

As to diet, we are for t^e most part content to follow the 
traditional warnings against salted food, spices, and preserves. 
I am sure that most children suffering from eczema benefit by 
a meat diet and some of them by tbe addition of stimulants. 
This also applies to antemio adults, and especially to the oase 
of women suffering from over-lactation or from menorrhagia 
On the other hand, adults in general appear to benefit by 
taking leas meat, no malt liquors, abundant dilnents, sod 
plenty of fruit itnd vegetables. In vasep of tbe prarigjinoQ) 



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Eczema. 333 

ecKms of the aged abstinence from fermeated liquors ib some* 
times snccessful, though I have more than once known it 
faU. 

The r^ulation of the diet of infants aaffering from eczema 
is of paramount importance. We often find that before they 
are folly weaned infants are fed upon potatoes and other food 
containing indigestible celluloae or excess of starch. It is 
easy to see the mischief of this. But eren when milk alone 
is given it often canses irritation, as shown by diarrhoea and 
vomiting; and if our local remedies are to succeed we must 
dilate it or mix it with lime water. Infants suffering &om 
dermatitis, with consequent pyrexia, often "crave" for the 
breast or the bottle, not from hunger, but from thirst, and 
thus complete a vicious circle by overloading tfaeir stomachs 
with food, when, if they coold express their wants, they would 
a»k for water. 

On the whole, internal treatment is most likely to be of value 
vhen used to help careful and energetical local treatment. 



III. FSOEIABIS. 

F^equtney. — Next to eczema, scabies, and syphilitic eruptions, 
psoriasis is the commonest disease of the skin among London 
oat-patients. 

Of ISO consecutive cases noted for the purpose in January 
and February, 1879, I found the numbers to be of eczema 45, 
scabies 29, psoriasis 19, syphilis 18, impetigo capitis II; of 
179 consecutive cases in the same months this year (1880) 
there were of eczema 32, scabies 27, psoriasis 16, syphilis 10, 
and impetigo capitis 32. In three summer months (June, July, 
and August) of 266 consecutive cases 37 were impetigo, 69 
other forms of eczema, 23 scabies, 21 syphilis, and 18 psoriasis. 
Uniting the three lists the proportion is of eczema 22 per 
cent. ; of scabies, 12'5 ; of impetigo, 18} of pBoriasia, 8'5 ; and 
of ayphilia, 8. 

Compaiing these figures with those of other observers we 
find that of the enormous total of 10,000 consecutive cases 
observed in hospital practice in Glasgow by Dr. McCall Ander- 
ton, 2$27 were ecaema, esactiy tlie ^ame pumber scabies, 72S 



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884 Observalions on Svperfidal DermatUu. 

pflorittsiB, 567 nDg^orm and other tinea, 517 B^hilodermia, ud 
827 phthiriasis. The same phyBiciaa foand among 1000 con- 
secutive cases in private practice 848 of eczema, 106 of paoriatii, 
101 of erythema, 67 of lyphilis, 86 of ringworm (beside fotir of 
faTOB, which is less rare in Scotland than elsewhere), 44 of 
scabies, and 54 of acne, and 21 of rosacea (t.e. gntta rosea at 
acne rosacea). 

Of Mr. E. Wilson's lOOO consecutive cases obserred in 
private practice, 298 were eciema, 112 acne (or gntta) rosacea, 
78 psoriasis (alpbos), 55 acne, 89 ringworm, 87 scabies, and 80 
syphilis. 

At the Bellevne Hospital of Kew York, Dr. Bnlkley fband 
among 1000 consecutive cases, 802 of eczema, 111 of acne, 98 of 
syphilis, 57 of phthiriasia, 50 of psoriasis, 48 of Mnec, and 86 
of scabies. 

Of 11,000 cases collected by the American Dermatological 
Association, from private and hoBpitftl practice throngbont the 
States, more than 800O were eczema, 1414 syphilis, 685 acne 
(excluding gutta rosea); and next came psoriaaia with 402 cases, 
followed by ringworm with 356, and urticaria with 883 (' Tr. 
Amer. Derm. Assoc. Philadelphia,' 1881). 

Terminology. — The natne psoriaaia is, like moct others in 
dermatology, of purely conventional significance; it is not 
a " condition of psora," for it has nothing to do with scabiei, 
and in most cases is attended with less itching than prarigo or 
than chronic ecaema. But the name is distinctive and nnivcf^ 
Salty recognised, so that there is fortunately no chance of 
"alphos" or any other displacing it.' Happily also the 
artificial and misleading use of lepra aa a synonym of certain 
supposed forms of psoriasis is now almost forgotten. One em 
only wonder that such an acute observer as Willan ahoold 
have admitted the distinction between lepra and paoriasii 
against the evidence of his senses, in order to fiallow the eon- 
fiised and sometimeB misinterpreted descriptions of Otcek and 
Latin authors. 

Hippocrates (' Aphor.,' iii, 20) speaks of leprae tc^ther with 

< " Fom citer nn eiemple, le pioriuii d'Eraemiu Wilion n'a rl«ii de congm 
■TBc rBflection aingi nawmia en Fnaoo." writes Dr. TMtj, ind qnoteftn 
Hr. WUwn : " PMriuii U a mitigatad moA ohnmio fam «f pwn ttt dtnon." 



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Pisrfofif. S8S 

Uehen and aJpAoanB diwaaei vhlch occur in the Bpring of the Tear. 
Qtlea (' De tomoribns/ xiii) makefl pmra and lepra "melaDchoHc 
diseaies of the Bkin alone ; if they affect the veiua and flesh 
tbef are called cancer," Panlos ^gioeta (lib. y, cap. 89) alao 
f^Upnra and lepra together, M roughaesa and itching of the 
ikin, "proceeding from black bile," i.e. melaDcholic ; but 
he diitingaiehea lepra thos : Sia ^ jdovc ivtvifUTat rb Bipfia 
EvrXorfpnip, fxtrA roG ^oXiSoctSiTc u^ccvat AcirfSa?. Tfaia does 
not ID Tell apply to paoriasia btit rather to the sqaamoos sad 
olceratiTe stages of cntaneoua ayphilis. Actuarius (lib. ii, 
cap. 20) describes lepra as less formidable than elephantiaeit (a 
term not used before Celsas and AretKoa), the next in severity 
bangps&ra (scabies), and then lichenes (impetigines). Lepra 
goes deeper than the latter and wastes away the akin (rfvo? 
nrvrji^tc vafiKoe woui) and givea off soalea — a mere repetition 
of the statement of j^gineta.^ Herodotna apeaks of persona 
■offering from Afirpa or \lvieti being compelled to live aeparately 
ia Persia (i, 138). The terms here are no doubt synonymous 
with what Tonld etill be called scaly and white leprosy respec- 
tirely. 

The Septnagint tranalators «sed \trpa as the equivalent of 
the Hebrew Zaakath, and \cvp6c is the word for a leper in 
the New Testament. Thence the word passed into all Euro- 
pean langoages, with the adjective Iqtronu, from which our 
form 'leprosy' is derived. 

After the word elephantiasis' was introduced, it was supposed 
to denote the most malignant kind of leprosy. Thus in the 
passage quoted above, Actaarius aaya; "Lepra is a less 
evil than elephas ; after it again comea psora, and then 
lichena." 

ARer the revival of learning, Gregory Herat, of Nuremburg, 
in hii 'Bpistola de Hymeue et Lepit' (17 — ), distingoishea 
Elephantiasis Arabnm as " a disease of the feet with great 
■veiling and distended veins," and correctly deacribea the 

' Thli and tba two preceding citaldoiia I raune apoa fn tfae expotition of Qreek 
wordi mod bj Hippocntef, AretcBn*, and other medical writen, pnbllihed b; 
Henrj Bt^ban, in 1664. 

' " Elephaatiaiii Qneeomm " ia a clnma; rapreaiion, which haa produced 
mdlen confaiLin of leproaf with Paohjdermift, " LapnMjr " and " Bubadoea 
%" biTB ausb a diflnita nwaning, Elephantiaiia haa dodb. 



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S36 ObtervtUunu on Superficial Drrmatitii. 

elephuitiasiB of the Greeks as the same with the lepra of the 
Latins and Arabians ; i,e. as leprosy {Auagats) ; and he describe* 
the lasar honses of Crermany at that time. 

In the eighteenth century the learned Dr. Head, in hia 
' Medica Sacra,' heads the chapter on the leprosy of the Bible 
iritfa the title L^ra morbtu. He says that lepra is a kind of 
scabies, and speaks of elephantiasis as leprae congener morbui. 
After qaoting the vell-knovn accoants of Celaus and Aretieiu 
he concludes : "Ex hit ^itur omnibus manifeetum fit, I^nm 
in Syria non nalard sed gradu tantum ab tUd in Grecid gv^ 
XtiiKn Un vocabatur divenam Jitiise ; et ipmm kune marbufk 
ihierdum apud Gracoi, maximi verb inter Arabat elepkaiUitr 
t^Snem/uitte. 

Dr. Daniel Tamer, in his ' Treatise of Disease incident to 
the Skin/ 1723, describes Barbadoes leg as leprosy of the 
Arabians, and elephantiasis as leprosy of the Greeks. 

Blancard's ' Iiexicon Medicam ' (Lugd. Batav. 1702), vhidi 
correctly distingniBhes Elephantiasis Arabam, de quo morbo ne 
verbumquidemfecerunt Grmci, from Elephantiasis Graeconiin 
guam Arabea lepram vacant, describes true leprosy as " Elepban- 
tiasis, sive lepra et leprosis ; " and translates it " Aossati, 
Lepre, the Leprosie." 

Heberden and Collea both affirm that they had never seen 
lepra, but the former describes psoriasis clearly enough as " a 
branny scurf observed in patches all over the body, and very apt 
to begin at the point of the elbow." So that the difficulty of 
which Bateman speaks' arises only from his refusing to 
recognise lepra as a term for leprosy. 

Liagnotia. — The discrimination of psoriasis from scaly syphilis 
is occasionally difficult, but in most oases the large, gliiteii- 
ing scales, the colour, the characteristic distribution, tbe 
uniformity of lesion, the irritability, and the recurrence of the 
attacks in precisely the same form, distinguish the former from 
the latter diseasej apart A-om the absence of other signs of 
syphilis. 

■ " It ii difficult, th«efore> to accoact for the opinion expreued bj tti« l>lt 
Dr. H«berd*ii rapecUog the extreme rsrit; of Lepra in thit coontiy. Aod 
■UU more difflenlt to explain tbs itatemeDt of Dr. Cnllen . . . tbat ho had Dern 
(9M) tbe djwwe."— 'Practical ^jnopBt,' p. 86, *»U (cd, ISM). 



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Paoriaait. 237 

Host of the c&acs which were formerly described as ptoriatit 
palmarit were no doubt squamous syphilides, aud others aeem 
to h&ve been chronic Eczema rimotuta ,- but I have certainly 
seen true pfioriasis affecting the palm, once in Vienna and twice 
at least in my own practice. In each of these cases the occur- 
rence of psoriasis in the usual situations made its recognition 
euj. The distinction of true psoriasis from eczema squamo- 
sum (i.e. of alphos from psoriasis, according to Mr. Wilson) is 
easy enough in practice ; the confusion is only one of words. 
Tbe distribution, the size and colour of the scales, and the pre- 
TiooB GonditiOD of the skin, are amply sufficient to distinguish 
them. 

Mtiology.-~-With respect to the origin of psoriasis, I am 
entirely incredulous of its connection with gout or with scrofula, 
or with any imaginary diathesis, dyscrasia or temperament. It 
is s disease of the skin and nothing else. I do not deny that 
psoriasiB may occur in a patient who has urate of soda in 
his joints, or in a child who has caseous cerrical lymph glands. 
If we never met with such cases, it would follow that gout 
or scrofula protected A^im psoriasis. But one may certainly 
see marked and inveterate psoriasis in the most varied 
conditions of be^tb, in the most robust and ruddy, as often as 
in the thin and pale. It is not a disease of tbe blood, nor of tbe 
hsmours, nor of the nerves, but of the skin ; and is as indepen- 
dent of other lesions as any other histologically local disease. 

Barin, Hardy, and French pathologists generally, supported 
by some authorities in this country, have assigned to psoriasis 
a leading place in the group of dartrous diseases, which has 
already been criticised under eczema. The hypothesis of a 
dartrous diathesis and the entire order of ideas to which it 
belongs, appear to me to be baseless in fact, unscientific in 
phndple, and oseleas or harmful in practice. 

Willan vrisely discarded the imaginary virtu dartreuXy which 
was in fact nothing else than the psoric humour of Hahnemann 
{la gale partouf) a humour now (I believe) given up even by his 
own followers. The disciples of tbe English school of derma- 
tology in France — Biett, Cazenave and Gibert, and Devergie 
maintained the same scientific and practical attitude, not 
framing hypotheses but observing facts. But the dartres were 



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S38 Oitervations on Superfietat Dermatitis. 

aguu brought into notoriety by the presumptnoas and histy 
dogmatism of Alibert, and have since, under various modifica- 
tiona, been recognised by hia Buccessors at St. Louia, by Basin, 
Hardy, Caillant, Guibout^ and many others. 

It any one viahet to judge of the lengths to wbioh this 
doctrine has been carried, I would recommend the peruaal of 
the bulky volume on "Herp^tisme " by M. Qigot-Suard. 

Taking with all respect the statements of the eminent French 
physician, M. Hardy, we find that the characters of the dartres 
are : 1, They are not contagious; 2, they are often hereditary; 
3, they recur ; 4, they itch ; 5, they spread ; 6, they are 
chronic; and 7, they do not leave scars. ^ By these characters 
" we are led logically to believe " that these dartres are due to 
ttn vice dartreux, vinu dartreux, or, aa M. Hardy prefers to call 
it, lUatkite darireute. The diseases, which are not local, bat 
true dartres, are beside psoriasis, ecxema, including impetigo, 
lichen, and pityriasis, including pityriasis rubra. To these 
other authorities add pemphigus, erythema, and many other 
kinds of disease, so that, excepting syphilis, herpes and oaooer, 
few affections of the skin have not been brought more or leas 
under the comprehensive dartrous hypothesis. 

We are told that it is possible to distinguish a dartrous 
diathesis apart from its manifestation in actual disease of the 
skin. " Lea persoones dartrenaes, bien qu'ayant en apparance 
tons les attributs de la bonne sant^ sent oependant dans uu 
^at particulier qui n'est pas la sant^ parfaite." Their skin is 
dry, and they do not easily sweat. Their skin readily itches, 
and is inflamed by slight causes, such as eating shell-fish (wbioh 
makes urticaria ah ingestia a " dartre," contrary to M. Hardy's 
classification elsewhere), and they have a good i^^ietite evea 
when they are ill. These characterB( excepting the last) appear 
to me to apply to eczema and to ecxema only. When the skin is 
irritable and readily inflamed we may say, if we pleaae, that it is 
"disposed" to common auperficial dermatitis, i.e, to ecMma; 

< "Ifon* ftppeUaron* iartru dei iflectlmu de Ik pean it IMoni SJmcnti^ra 
ditMrentei, noD oontagieaui, m tnnimettuit couvent par Toie d'hIrUiU, m 
reprodniMiit d'one mani^ preiqne coutante, pr^Mntant poor symptAaie prin- 
cipal des d^maageuaoiu, toujoon dispoifei i. enrahiT de nouvellea rfgioni, k 
marche habitoellment cbroniqae, et doot la gu^riioii a lien una doatricei, bien 
qi^ellea (^acoompagDent wniTent d'nlc^tioni." — ' Le90iu inr let Hslsdiea de bi 
Pe»u,'p. 19: 

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or that the akin (not the person) ia of an eciematoai comtroc- 
tion or " conatitatiou," oi an ecaematoos diapoaitioQ or " dia- 
theais." But patieota who often tnflbr irom ecaema are not 
particularly liable to paoriaais, uor to acnte erythema; and 
there ii no reaaon to anppoae that their blood (any more than 
tbair norrea or braint) ia different from other people's. 

I jQo hin g to the aigna given abore, which are to juatify one 
in aMigning an aotoal eraption on the skin to a dartrona 
wigin, we find none i^ them aaffident (1) Lnpna is not 
oontagioaa yet it ia not a dartre; poatnlar eciema ii often 
coutagioaa yet it ia a dartre. (2) Hereditary tranamiaaion 
praree only that a diaeaae ia not accidental or tranmatic, not 
OMtagiom and not paraaitie. What ia hereditary is a certain 
Btmcture of the akin^ aa of other organs, as stature, aa malfor- 
aatio n a , aa shape of limba and head and nails, as colour of akin 
and hair uid eyes ; or again, func^onal pecoliaritiea, aa early 
or late baldneaa and greyneaa, early or late atheroma. Every one 
admita that ecaama ia often hereditary and that psoriaaia ia ao 
also; bnt what wants proof is that any common state ia 
tranamitted which may turn to one or the other. Moreover, 
other diaeaaee of the akin not conaidered dartrona are often 
hereditary, aa cancer^ leproay, and even erythema nodoanm. (4) 
Itching ia kaa characteiiatic of paoriaaia than of prurigo, 
nrtiearia, and seabiea. (7) Not leaving scare shows only that 
the papilla are not deatroyed and appliea to all other superficial 
aflSectione of the skiu. The remaining characters, chronic 
coniae, gradual spreading, and aptness to recur, are no doubt 
pointa of agreement between eczema and psoriaais. 

That there is a pathological relationship between them may 
be admitted, but it is chiefly one of contrast. Eczema ia often 
acote or subacute, psoriasis ia chronic ; eczema is at one time 
or other moiat, psoriasis never ; eczema affects the ftexures and 
the thinnest parta of the akin, paoriaaia the most exposed and 
thickeat regions : ecaema i« the moat varied of diaeases in ita 
outward fonn, psoriaaia the moat conatant; ecsema can be and 
often ia produced by direct irritants, paoriasia ia always idio- 
pathic. 

Apart &om the apecial question of the origin and nature of 
paoriasia, I may here be allowed to repeat that the whole order 
of notions expresaed by auch terma aa " conatitution," " diai- 

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240 Observations on Superficiai DermatttU. 

thesis," "temperameut," appears to me to be a aumral of 
exploded physiological Byatems and only obstructire of investi- 
gation. Constitution means a certain stmctTire of the solids of 
the body. Temperament means a certain tempering or mixture 
of the hnmoors of the body;^ dyscrasia an ill mixing of the 
same humours. But the humoral pathology is dead. Tbere is 
no mixture of blood, bile, phlegm, and black bile. The spleen 
is not a gland, and melancholic patients are not, by the testi* 
mony of the deadhoose, " splenetick." If there was any 
accidental truth in the doctrines of the humoral pathology, it 
must be proved anev by careful investigations into the pre- 
valence of certain diseases in the lower races of mankind. 
Certainly bo mixed a population as that of England is ill fitted 
for such inquiries. 

It was once believed that the skin was a chart on which the 
hnmonts of the body displayed their signs for the scmtiiiT of 
the physician, just as we now look on the tongue chiefly as an 
index to the state of the stomach. There was foundation for 
such a theory in the case of jaundice, of syphilodermia and of 
febrile rashes. But we now know that most affections of the 
skin are strictly local and structural. If it can be proved thst 
psoriaris occurs more often than the doctrine of chances voold 
explain in persons subject to gout or to acrofula, and if «e 
thereby learn how better to treat onr patients, the proof 
will be a welcome addition to science and to practical thera- 
peutics. But gout must mean not an arbitrary assumption, 
but the existence of urate of soda in the tissues ; uid scnfals 

I " If the Element of Fire be Chieftain, the Body is raid to be Cholerick ; if 
Air bear rote, to he SnnguiDe ; if Water be in bii Tigonr, tbe Body ii (ud to be 
Phlegfmatick ; if Earth have hit Dominion, to bs Melancholick. For Choler i< 
hot and dr; , Blond, hot and moiit, Water, cold and moist. Earth, cold and dij- 
Theie four compleiion* (or temperament ■) are compared to the four ElemenlA 
tecondlj to the fonr Planeta, Mara, Jnpiter, Saturn, Luna, then io tbe fmr 
Windi, tben t« tbe four Seaioni of tbe jear, flftbl} nnto the twelve Zodiical 
Si^ns, in whom are fonr Triplicitiea, lastly to tbe four Ages of Man ; all of vbicli 
are here deciphered and limned ont in their proper orbt,thna: L CkoUriet, 
Ariel, Leo, SKgittorini ; Mare, Ignit, Favoniui, Aestas, JuTentoi. II. Ssv"*"' 
Gemini, Libra, Aqnariaij Jupiter, Aer, Anator, Ter, AdoIescentU. IIL FUtj- 
malich, Tanrae, Tirgo, Capricorciii ; Luao, Aqoa, Autnmnni, Tergeni, Aeti>- 
IT. 3I*la»cho}icJc, Cancer, Scortno, Piice*; Sataraai, Terra, Aqoilo, Hyena, Sc- 
nectoa." — '.The Optick Qlawe of Humoun,' 1661. 



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Paoriati*. 24.1 

must not mean vagaely ill-heslth, bnt csmoob dq^eneration of 
lymph glands. 

Until, therefore, «e leam better, we mnat conrider that 
paonaais is not dae to a supposed arthritic, herpetic, or dartrons 
diathesis, that it is not a manifestation of gont, and that it has 
no more to do with scrofula than vith syphilis. 

Agfttu, we cannot trace psoriasiB, as we so often can eciema, 
to a local irritant. It cannot be excited at will, it is not pro- 
dnced by son or cold, or sweat or inetion, or mostard, or 
Tenons congestion. It is scarcely an inflammation, certainly 
not an exudation in the sense of Bokitansky and Hughes 
Bennett, 

But the histological appearances are decisive of its being a 
true chronic inflammatioa of the Malpighian layer and sub- 
jacent papillfe, with hypertrophy of the latter and sabsequent 
atrophy of the former.^ And occasionally we see the early 
stages of psoriasis, like those of syphilodermia, showing the 
ordinary signs of inflammation. 

Cm. — A young man came to me with a bright rose rash, 
which had appeared the day before in minute patches over his 
chest. It looked like early syphilitic roseola, but there were 
no other secondary symptoms and no evidence of infection. 
There was slight local heat and general malaise. Two days 
later he came again, perfectly well in himself, with the rash 
changed into a papular form and several of the papules covered 
witlt imall white scales. In a week or ten days an ordinary 
Ptoriatig gititata had developed, which soon yielded to remedies 
and has not returned. 

The early origin of psoriasis, its almost constant distribution, 
its frequent repetitions, and its appearance in different members 
of the same family, point to its being an inherent and not an 
accidental vice of the skin. 

Though most cases of psoriasis appear to be free from here- 
ditary inflaence, we sometimes meet with such marked instances 
that we must admit it among hereditary diseases. In this 
Tctpect it resembles carcinoma and rheumatism. 

I need scarcely refer to a lately propounded hypothesis that 
psoriasis depends upon the presence of a fungus, for it is 

' Sw the flgnre* by Nenmaim, ud an intereiUng pnpw ^ Dr. Thtn, in the 
'Brilith HedkU Jonnul ' for July, 1881. 

VOU XIV. 16 

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£42 Ohtervaiumt <m St^erfietal DermatUig. 

contradicted bj kll ve know of its conne and origin, aa veil 
w by miaroecopical investigation of the BcaJes and of th« 
ekin in sectioo. Dr. Yandellj of St. Louis, reoogoited MToal 
of mj cases ai malarial in origin, but the endence did not 
conriace me. 

fbrm and iSttriMion, — The form of psoriasis is remark- 
ably constant, and its diatribation scarcely leu so. It is 
always the dry, scaly tetter, always bilateral, and often eiacUy 
symmetrical, but never, I beliere, uniTerHal. Symmetry has 
been said to prove that a disease is " cxinatitatioaaL" If Uiii 
means only that it is not traumatic, it is true enough, hut if it 
means that the symmetrical disease is due to some aoomsly of 
the blood like leacbemia, or to some generalised condition like 
carcinoma, I can see no justification for the dictum. The 
lesions of the skin in parpora, an affection of the blood and 
blood-vesaelfl, and in syphiLs, a generalised disease, are far leu 
symmetrical than in psoriasis and idiopathic eciema, which are 
both strictly confined to a single organ. The two elbows are 
not covered with scales because they are both supplied with 
the same blood, for do part of the skin (or mnoous membrane 
either) has its private supply of nourishment. The two dbowi 
are affected with psoriasis because their akin ia more alike 
than that of any ether part of the body. Next in likeneu 
u the skin over the knee caps, and least so the skin of the 
axillK. 

The varieties described as Paoriasia punctata, guttata, mwi- 
mulata, annulaia, gyrata, &c., depend chiefly on the period 
at which the disease is observed, and are of no scientific, that ii, 
of no practical importance. There is, however, one form of 
this affection which seems to me to be distinct enongh in more 
than mere accidents of appearance to deserve notice m a 
variety.^ (1) It is guttate in figure, the separate spots not 
coalescing as usual into larger patches ; (2) there is little red- 
ness around the scales ; (8) the distribution is much Um 
regular than usual, the whole trunk being often spotted over 
and the elbows and knees free ; (4) it scarcely itches at all ; (&) 



1 Since vriting the aboie I b*Te notieed in Dr. Ut^ii^i ti o« l la rt ' 1 
of ibe IH«giiMii of Skin Diaeuea,' p. 1£0, a rer; umiltr «ca<nmt ot «b*t Im 
eaUed Scioruloiu Ptoiiuii. 



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Ptoriatia, 



Z4» 



it occnrs almost invariably ia children ; (6) it often does not 
require arsenic, bat is BnccesBfally treated with ood-liver oil, or 
sometimefl with steel. 

This want of eonformity to the typical geography of the 
disease is what may be obserred in other cases of children's 
pathology, in pnenmonia, for instance, and In tubercular 
disease ot the abdomen, in afEaotionB of the joints, and of the 
eye. In the case of the skin we may perhaps say that the dis> 
tribntion of morbid processes is less precise than in the adult, 
because the several regions of the skin are less differentiated, 
because the skin of the elbow, the hand, the back, the chin, is 
much more alike in the child than in the man. 

PlorJont (^ the nmb and of the tongue. — The nails are seldom 
■ffocted except in the most severe and extensive forms of the 
disease ; yet malformations of the nails are more frequently doe 
to psoriasis than to ecsema, ringworm, syphilis, or any other 
general disease of the skin. 

Beside the well-known patches of thickened epidermis on 
the dorsum of the tongne, which go with fissures, nodes, and 
other undoubted syphilitic lesions of the part, aud beside the 
chronic indolent patches of " psoriasis " or ickthyoeu lingua 
which precede epithelial cancer, there is a true psoriasis of the 
oi^an, which though rare may be met with in cases of the 
disease; and I have twice observed it in connection with lichen 
planus of the body. 

The following are notes of the points indicated in fifty-five 
eonsecative cases of psoriasis lately nnder treatment : 



IT*. 


Bci. 


At*. 




Dantion. 


'""l^- 




K 


SB 


Oi^uTT A. muai albovn 
Mid knwa >dM«d 


SSyeui; once free 
for 8 jean 


One brother. 




P 


IB 


Ditto 


Since chUdhood 






U 


Adult 


Ktto 


S months. 






T 


8 


Ktto 

Ditto, eibeniive ; fMe, icalp, 
band*, and fM only free 


i yeusi every 
apnng and fkU. 
S jcftn. 





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Obtervationi on Superfitiai DermatUii, 



Ko. 


Sm. 


if.. 


Fom uid lutrilmtkiii. 


DmUm. 


f^\^. 


8 


K 


22 


A. gttttOa, elbowi Uld 
kneei Inw( both nwd to 
beKffeeted 


First at 16. 




9 


M 


aft-26 


Almart UDiTBTul. induding 
palm* and band of elbowa 


Sereral years. 




10 


T 


18 


Elbowi, ki««i, and tlmbi 


Ditto 


Mother and 
two niters. 


11 


H 


4 


iV, jirftoto; elbows and 
kiiwi 


P 




12 


H 


28 


A. ^irfteto,- olbowB and 
kneel not ailected 


6 OP 8 years; began 
at Gibraltar. 




18 


P 


e 


OrdinaiT pMriadi j elbowa 
andkoeea 


P 




U 


P 


u 


DMd 


4 years; every 
spring. 




15 


M 


21 


Ordinarj, bat eitonrive and 


lyear 


Father and 
mother died 
of phthisis.' 


IS 


F 


18 


Otdinarj, leatp nmeh af- 


10 montbs 




17 


F 


88 


Ordinary, extenun, inclnd 
lug pabn and kIw, and a 
patcb of iV. loffua 


e montbs 




IB 


F 


7 


Ordlaary; elbowi and 
Imees 


P 




19 


F 


6 


Ordinary, mclndinj[«»lp 


at years 


Father. 


20 


F 


9 


Ordinarj; elbows and 

knee* 
KnoDi, thigha, and c«l*ei 


P 




ai 


F 


40 


One attack 7 yean 










nowhere else 


X.1^- 














22 


F 


M 


Ordinarj 


4yeara. 




28 


F 


8 


Ordinary 


Second attack 


Father and 
brother. 


at. 


F 


a 


Ordinary 


P 


Mother of 26. 


25 


H 


8 


Pt.punvUilai tmnkoiaj 


P 


Son of No. 24 


26 


F 


26 


Pt.o,tlata; limbi ool; 


Freqnently rec-nr. 




27 


K 


20 


Ordinary I scalp 


P 




28 


H 


16 


Ordinar J ; leg* only 


P 




29 


K 


27 


Ordinatji soalp 


P 




80 


F 


U 


Ordinary 


7 yeiMi wpiog 
and antnmn. 




81 


H 


60 


Pt.gmtlata, tnmk. Aente 
eciema ot bead and neck 


P 




82 


H 


80-26 


Serere and general, cbiefly 
Tt.gsralat not speeiaUy 
on knaas and elbows 


First attack! sere- 
n1 months.' 





1 Tlui paUent was himself a robnit well-bnilt young man, a working engineer. 
He had been frae from all affections of the skin nntil the spring of 1879. Ha 
was treated elsewhere front September to December with no benefit, first with 
iodide of potasainm and then with small doses of arsenic He completely 
ncoTered by Febmary nnder tall dose* oTarsanie and local applioation of tar. 



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...^ 


*«fc 


r,^uddi.tribiiUon. 


:wl«. 


l^l^UtarX, 


ss 


M 


S£ 


lata, trnnk and Umbi, 


SeooQd attack 1 
Brat at SO. 




u 


H 


18 


Ortinwy, indoding inlp 


f 




3S 


9 


89 


Orfiimiy, TOTj ganonl; oom- 
pUnted wilb ordintr? 
ecMBW, intorfariso of Dum- 


Third attMki with 
each, lactation. 




se 


K 


28 


Ordiairr, Mii>pUot«d bj « 
tJOQ nom ■ lurd cbancTe 


SsTvaljean; nm- 
aUy each .pring. 




87 


K 


84 


Ordinwy, «ry gener.!, not 
ipceiaU; on elbows ud 
knsei 


From chikDiood) 
worM in iprios 

and antnmn 


Mother. 


ss 


P 


43 


ft. jjwifl/ neck, thnwt, 
gheit^ mud nape, down to 


After each deli- 
larj, ij. twdT. 




t9 


H 


27 


kneei. abdomen 


2 montJu; MMond 
attack : flnt 




40 


F 


SI 


0KUn«i7j elbowi utd kneei 


Third attack) E 




a 


U 


» 


Ordinarji ezteniiTa 


Fifth attack liiiM 
S yean old. 




ti 


f 


47 


Ft. guttata; both toreftrnu 


Pint attack; 6 

month* 
Pint attack ; S 

monthi, 
4 year.. 




43 


F 


18 


Ordinary; uuuiDdlegi 




M 


H 


40 


Ordioirj ; limbt and (calp 




45 


P 


*t 


Oidinar;; armiutdlegi 


Third attack. 




16 


P 


58 


Ft.giatata! knee and anklej 
»erj irritable 


Pir»t attack 


Haihadgont. 


47 


P 


14 


P». guttata, •««, cheat, 
b.Sr;«nJknee. 


Second attack: 
flnt when 11 




■ IS 


P 


18 


Kneea and elboivB 


Repeated; every 
ipring. 




«■ 


M 


20 


OeaeraligutUbaanddiffnH 


Pirat 




M 


F 


30 


Elbows and kuoei 


Second; flrrt 18 
month, ago 


Father had a 
" dlMau of 
the .kin." 


EI 


P 


44 


imw, *«., palmi, nail* 


Several year* 




ES 


H 


54 


Ordinary i general 


Since 14 


Mother had 
the tame. 


53 


U 


IS 


Ordinary 


Pint at 17 




54 


U 


10 


Ordinary 


Pint at 9 




U 


K 


58 


Elbow., hip., leg. 







' "m* patient had been previooily treated for syphllU without benefit. The 
lUttribaUan waa romewhat mi.lending, but he rapidly improved under armnic. 

' While this yoang man was ander treatment, and the eruption gndoally dii- 
appeariag nnder lolntion of anenic, of which he wa. taking ntv^ Uiree timea a 
dij, there ivddenly oeenrr^d an eoa^ onl^bTenk o% iini|iber)en frnli epot* «( 



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346 Obtervationt on Svperfiaal Dermatitit. 

The following ia an aaomalons case of disease, remarkable io 
more than one aspect, which I have with some hesitation 
regarded aa an aberrant form of pBoriasis. 

Casb. — George T— , st. 17, is a florid, fairly nourished lad, 
with the left leg wasted and contracted from obsolete disease of 
the hip. He never remembers being free from the affection of 
the skia for which he now seeks relief (Feb. 1, 1878}, He be- 
lieves it ased to be on his face, and is sure that when he was a 
patient under Dr. Frederick Taylor, in 1876, his neck was 
affected. About Christmas time (1877) it spread over his 
abdomen and loins. The adjacent parts of the trunk and 
limbs have been the constant seat of the disease. It is 
now distributed over the shoulders, arms and forearms, flanks 
and abdomen, buttocks and thighs, with an imperfect sym- 
metry. The scalp and face, ears, neck, legs, hands and feet, 
and genitals, are entirely free, and (excepting the head] appear 
to have been always so. The diseased surface is for the most 
part slightly injected, without pigmentation, papules, or other 
lesion, and with no evident cicatrices. Towards the mai^nb, 
which are more or less gyrate, it becomes more red, somewhat 
raised, and covered with small, white, adherent soales, which in 
most parts form a series of concentric margins. 

On removing these scales, a somewhat pigmented and in- 
jected surface is found beneath, without the least trace of 
moisture. 

Though there is no pigmentation of the regions now affected 
there are maculae on the chest and abdomen, where the patient 
states that the same eruption has existed. There is moderate 
irritation, no active symptoms. The colour is red or slightly 
parplish, without a coppery tinge. Careful investigation shows 
absence of all signs of either acquired or congenital syphilis. 
Repeated microscopic examination demonstrates that there is 
no fongns present. The sebaceous glands are apparently not 
affected. 

After some trouble I found the mother, who is herself a 
healthy woman. She says that her husband is deaf, but free 

Ft. guttata, chiefly on the armi, bat iIm) on the trunk and hgt, where the 
originel eruption was marked by little more than pigment gpoti. He wa> fioilly 
cored by taking bim into the hoipltal, uaag ttz tharonghly and pnibing tbe 
doM of Fowler's tolatlon to la^v thrice daily. 



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Pforiaatt. 247 

from tnj diseue of the skin. She has snSbred from lore hsnds, 
apparently M««m« rimotum. She has four other children, one 
older and three younger than my patient. One only of them 
lui any affection of the dtin. This girl afterwards also came 
under my care. 

U. T — , nt. 15, a healthy> well-dereloped girl. Xiike her 
brother aha was bom healthy ; bnt he was first attacked by 
his pnsent camplunt when about seven years old, and she at 
the same age or perhaps a year later. The skin of face is 
somewhat red and rongh. The shoulders, upper arms, aad 
chest are oorned with a reddish, serpiginous, scaly eruption, 
with smooth, rather pale patches inside the circles, or the gyri 
whidi are made by their ooafluence. There is no moisture, no 
cictbrisatioQ, and the disease is in all respects identical with 
that described in her brother. Here, again, there was no 
fongos present, and absolutely no evideaoe of syphilis, her^ 
ditary or acquired. 

Putting aside the diagnosis of lupus erythematosus, from the 
absenoe of nodules, of sebaceous implication, and of cicatrisa- 
tion) and that of tinea, from the absence of spores — it ap- 
peared to me that the only name to give it, if any known 
disesae, was that of psoriasis. The appearance in brother and 
lister, tba dryness and soaliness, the mode of progress, the 
inveteraey and proneness to exacerbations, as well as the 
itching and the pigmentation following its involution, all 
woglied with me in this decision. I accordingly prescribed 
Fowler's solution in gradually increasing doses, and Qeotge 
T— eontinned his medicine with great regularity up to June 
(1878), when he was taking fifteen or twenty drops daily. He 
then came to show how moch better he was, and indeed the 
eruption had almost but not entirely disappeared. He then 
gave up attending, and I did not see him until the end of 
August, when he came again almost as bad as before. Again 
I lort light of him till the 8th of October, when he resumed 
bis former prescription, and again improved. After three weeks, 
thinking himself better, he gave op treatment once more. He 
came towards the end of November with increase of the disease 
sod fresh oircinate spots on the chest ; there was also more irri- 
tttion than before. I then ordered a larger dose of arsenic and 
Liquor Caibonis Detergens locally ; but as soon as he improved 

. „Gooj^lf 



248 Obtervotiotu on Sttperfieial DermoHtu. 

again he ceased to attend, and I have not been able to see him 
siitee, thongli I havB heard of him at other hospitals. 

So far, the result of treatment voald seem to confirm the 
diagnosis. I should add, that before seeing me he had been 
treated with arsenic vith apparent benefit, that he had taken 
lAq. Hyd, Perehl. for several weeks without any effect, and used 
BolpIitirouB acid lotion vitb the same negative resnlt. 

On the 18th of November, 1878, I showed both this patient 
and his sister at the Ilanteriaii iSociety, Several experienced 
dermatologists, who then saw the cases recognised their resem- 
blance in certain points to erythematoas lupus, syphilis, and 
tinea, bnt all agreed that it was none of these. Mr. Hutchin- 
son, to whom I sent the patient, told me that the nearest 
resemblance to it he had seen was in a young man firam 
Canada, the subject of an eruption which had existed from 
Inrth ; it was not syphilis or tinea, but resembled ichthyosis 
and resisted all treatjnent. 

I have no doubt that Gteorge T-^ is the same patient whose 
case was described to the Clinical Society two yean later by 
Dr. T. C. Fox (' Lancet/ November SOth, 1880), as persistent 
gyrate erythema. "Wlietber erythema shoold be extended to a 
' scaly eruption whidi persists for years is a question of terms ; 
but if OTythema is used as a synonym of dermatitis, the 
question still remains as to the pathological nature of the 
disease. 

I am indebted to my friend Dr. Cavafy for the "suggestion 
that my case might, perhaps, be regarded as coming under 
what Dr. Duhring has described as PityriaBis macolata et 
(nrcinata : see his treatise on ' Diseases of the Skin,' 2nd ed., 
1881, p. 805. 



IV. LiCHKN AMD OTHXH FaPHUB FoKUB OV DSRIUTITIS. 

If we examine the descriptions given by Willan and his 
followers of the three classical papular diseases, lichen, 
prurigo, and strophulus, with their several species, we find 
very little which corresponds with the necessities of modem 
pathology. 



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Uehen. 240 

Willan defines lichem aa " ao extenBive eruption of papula 
affecting adults, connected with internal disorder, nsually 
tenninatiDg in scurf, recnrrent, not contagion!." Escept the 
fint anatomical character and the last negative one, there 
)> nothing here to help us, STaoPBtrLns appears to mean 
nothing but papnles occurring in children, which are not 
contagions, i.e. neither scabies nor measles. The term is de- 
serredlf neglected at present ; and the varieties of " red gum " 
are referred to papular erythema. Bateman's seven species of 
hcben are L. aimplez, pilaria, eircuttuer^ius, agnu$, Uvidut, 
tropieus and tirticatut. The last would seem to be iudistia- 
gniihable from Prurigo infantilis aa described by Hatchinson 
and other writers, which is generally accompanied with more or 
less consecutive erythema and urticaria, the wheals and the 
dif^iaed redneas being alike the result of scratching, and not 
the origin of the papules. 

The term lichen with a former generation included what we 
nowcall papular syphilis. It was also applied to the accuminated 
papnles most marked on the extensor surface of the upper arm, 
the calf, the outside of the thigh and the buttocks in brawny 
men (Lichen pilarit, pityriant pilarit of Devergie) j these are 
dne to accumulation of dry sebum and dead epidermis in the 
lu^ sebaceous ducts and hair sacs of these regions ; and they 
sometimes form minute centres of inflammation and even of 
tappnratiou. The condition is removable by friction with soap 
sad hot water, and scarcely deserves a pathological recog- 
nition. 

The same condition, however, occasionally occurs in a more 
remarkable form as the following case shows : 

lAehenpilarig of litabs in a child. — A thin, delicate looking 
^1, twelve years of age, was brought to me for " roughness of 
the skin." There was slight branny desquamation without 
redness or seborrhoea of the face and scalp ; but the limbs were 
covered with small, hard, pale, pointed papules, more readily 
felt than seen. Each corresponded to a hair-sac, and resembled 
the ordinary lichen pilaris of the thighs and legs in adult males. 
The papules, however, were harder EUid closer set, and affected 
not only the eitensor aspect of the limbs, but the soft skin of 
the elbow and ham, covering in fact the whole of the thighs, 
1^ and arms. The back and trunk generally] were fn^. 



360 Obiervationa on Superficial Dermatiti». 

The affeotion vas not congenital and had only appeared mnce 
the child was eight yeara old. Though thin and pale, the 
patient had no disesae of the lunga, lymph glands, jointg, &a., 
irhich could enable one to call this Lichen terf^Kloaorum, and 
it will he seen that the eruption did oot correspond with Hebra'i 
descriptiou of that afiection. Oa the other hand, it was 
obviously different from Lichen rmier, or any inflammatory 
disease, and would pathologically seem rather to be allied to 
pityriasis, xeroderma, and the rough dry condition of the skin 
in children which is connected by intermediate grades with 
ichthyosis. 

Lichen affriu$, with small vesicles and liability to terminate in 
a chronic pustular disease, is certainly a form of acute eoaema. 
So is L. tropiau, of which I have given a case above. L. 
Uvidtu is purpura affecting the vascular hair sacs. There 
remain only L. aimplex and L. circunucriptut. The acute 
course and slight desquamation of the former seems to mark it 
as a true erythema. The latter alone of all the species would 
probably be admitted as lichen by a modem physician. 

The acutepapularernptians, especially on the limbs, which have 
been described as lichen by later writers, may be ^rly classed 
under papular erythema, when, as is often the case, they justify 
the name by their rapid course, their frequent reourrenoe, their 
appearance in patches, their distribution, and their oonneotion 
with gastric disturbance. Lastly, I would recognise as ewema 
all papular eruptions which are chronic in course, diffused and 
spreading in their distribution, and locslised in the flexures of 
joints, the back of the ears, and other favourite ecaematoua 
sites ; which are attended with itching rather than pain, which 
lead to infiltration of the skin, and which either follow or 
precede ordinary moist ecsema. 

The species of Frukiqo described by Bateman are : l.Pr. 
tniiit, mostly affecting young persons, and sometimes ending 
in " contagious scabies." 2, Pr, formicant, occurring in adults 
and affecting the whole of the trunk and limbs, except the feet 
and palms, " but most copious in those parts over which the 
dresa is tightest." 3. Pr. senilii, in the course of wbioh 
" pediculi are not infrequently generated." 4, Looal pmrigo, 



oy Google 



lAehat and Prurigo. %6\ 

differing from the abore Tarietiea in not being papular, and 
onl/ resembling them in itcbing, viz. Pr. pre^utii, Pr. ptUtU, 
Pr. urethraUt, Ft. podicu, and Pr. pitdendi. 

The first of these is the result of irritation from dirt, and the 
second of pedicoli. The third it not prurigo at all, for it is 
second«ry to affections of the bladder, and modem pathology 
sepantea those affections in which papules if present are the 
e&ct and not the cause of itching, the direct traumatic result 
of seratching, and names them " Fmritas." Pntrigo podicit 
and Pr. pudendi, still so called by some French writers, ia 
QMDed Licien podicit b; Hardy and Eczema am by Bacin. 
It is the well-known chronic, intensely irritable dermatitis, 
onully papular, but often made eczematous by scratching, which 
affects the vnlra, the perinteum, or the anus in persons past 
middle age, and has been included aboTe under Eczema. 

Much of what was called Pr. formiean* and nearly all Pr. 
lau&i was probably due to pediculi corporis and now known to 
be curable by destruction of these vermia. 

There remain two ralid diseBses called Fmrigo. One is 
Hebra's prurigo, which I hare seen at Vienna, and which 
sppeara to occur occasionally in its full severity in America, 
Such cases, however, seem to be only remsjkably severe, 
and posdbly orer-described, cases of what we see in England, 
obstinate and chronic prurigo of adults, with thickened and 
pigmented skin, but without the characteristic localisation of 
iV. pe^euiaris, and unaffected by parasiticides. Such cases 
are in fact recognised by Hebra as Prurigo timplex. The 
other distinct form of disease is that called Prurigo ivfasntilit, 
StrephiduM, and Ldchen vrticatut, an obstinate eruption of 
Ui^, flat, rather pale papules, chiefly confined to the trunk 
snd adjacent part of the neck and limbs, and always avoiding 
the &ce, scalp, hands and feet, attended by intolerable itching, 
intgect to periodical exacerbatioas (whence it has received such 
names as sommer prurigo), and rarely seen before weaning or 
ai^ the approach of puberty. It is passible that some of the 
voTst of these cases may go on to the prurigo simplex of adults, 
oreven to its severer forma; but as observed in children the skin 
is not thickened, pigment is not increased, and the hands and 
feet are markedly exempt. That some of these cases are due to 
initants, and especially to fleas and other vermin, is possible. 



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353 Obtervationt on Superficial DermatUit. 

but there maat be more than the direct result of sncK irritatioiis 
to produce prurigo ; for they often Beem to hays little effect^ 
and when this follows it is usuallf an erythema, which dis- 
appears when the cause is removed. la contrast with Prurigo 
pedieularu we may therefore fairly call this disease idiopathic. 
I have seen one marked case of this form of prurigo following 
weeks after an attack of varicella, as described by Mr. Hatchin- 
Bon. 

The following are brief notes of cases of prurigo as above 
defined : 

Casb 1.— M., set. 48. January. Papules on shoulders, fore- 
arm, and loins; slightly on abdomen. Head and face and 
limbs free. Large, flat, discrete papules, with scratch marks 
and slight erythema. Severe itching. Subject to it since 
childhood. Two months later the forearm, buttocks, and 
thighs were also affected. Treated with quinine without 
apparent benefit. Ko pigmentation. Not due to any dis- 
coverable irritant. 

Cask S, — M., nt. 42. July. A similar case, but more 
extensive, the limbs as well as the brunk being affected. Back 
and shoulders less so than loins, buttocks, and limbs. Head, 
face, hands, feet, and genitals alone free. Paptdes separate, 
and many capped with dried blood. Scratch marks, with a good 
deal of erythema and urticaria. Seven years' duration, always 
worse in summer and better in cold weather. 

Cask 8. — F., set. 15. October. Generally distributed; 
papular. Was, dbring the summer, a patient of Dr. Fagge, 
who treated her with marked success by full doses of quinine. 
Three grains of the sulphate taken three times a day appeared 
agfun to be extremely useful, and after a few weeks' treatment 
she was again freed from her troublesome complaint. 

Case 4.' — M., tet. 12. May. Large scattered papules, some 
with bloody tips, over back, nates, thighs, arms and foreams. 
Six months, from November to May. A thin pale boy. 

Cask 5. — M., set. 12. Papules and scratch marks, without 
pigmentation, on back, loins, thighs, and (slightly) on upper 
arms. A pale thin boy, Pediculi corporis. 

Case 6. — M., Eet, 12. Scattered pmriginous papules. Q-reat 
benefit while taking quinine and using hydrocyanic acid (^iv of 
the dilate acid to & pint) as a lotion, 



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Pruriffo. 258 

Casb 7. — M., set. 6. May. Small, colonrleM, almost 
invisible papules, none closely set, vith raised patches (tf 
ttrticaria. LoiiiSi abdomen and limbs. Head and face, 
ahonlders, and hands and feet qoite free. Has lasted two 
years. Impetigo capitis before. 

CisB 8. — M., EBt. 1^. Large, flat, pale, discrete papnles over 
liuk and abdomen. Some urticaria. Slight eczema of one 
sxills. A fair, weU-nonriahed child, tfo source of irritatioD 
discorered. 

Cabs Q. — M., xt. 4. January. Papules and scratch mariu 
over back and shoolders. Began last snmmer. 

Cask 10. — M., let. 3. Small discrete papnles, with a few 
vesicles and scratch marks, but so erythema. Abdomen and 
tmnk generally ; arms and l^s also affected. ExcessiTe irrita- 
tion. A healthy child. No irritant discovered. Treated with 
qoiniae without benefit. After several months, gradual im- 
provement independent of treatment. Next August relapse. 

Cask 11. — M., set. 2. March. Had chicken-pox aboat a 
jeax ago. For three months has suffered from exceedingly 
irritable papnles, with pustules. The disease was first called 
lAchn urticatus, then " Erythema pustnlosum et bulloBom," 
When I first saw it, I suspected scabies, but a careful search 
failed to discoTcr not only the acaras (a common failure in the 
caw of infonta), but any runs, resides, or other characteristic 
leiion. MoreoTer, the distribution was unlike that of scabies, 
the papules being irregularly scattered over the trunk and 
limbs, and there was no other case. The pustules and blebs 
vere due to the child's scratching, and were accompanied with 
Thesis of nrticaria. It continued very obstinate for several 
weeks. 

Case 12.-^M., let, S. January. Colourless papnles, with 
■Ught erythema on chest, hips, &c. Head and limbs free. A 
well-nourished, healthy child. No trace of vermin or other 
irritant. 

Cask 13. — ^M., set. 3. Papnles with slight erythema, with- 
out wheals, over loins, back, arms, thighs and legs. Five 
months' duration ; began in September. 

Cabs 14. — P., Eet. 4. Papular rash on abdomen, flanks and 
bins ; bead and limbs firee. Summer prurigo. Well during 
tlie winter, and came again the next spring. 



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8S4 Observatiom on Buperfiaal Dermatiii*. 

Caiz 16. — In ■ child, st. S. Jane. Pale tcatterod pftpnies, 
one only baring beoone Teaicnlar, otw tlie ftbdomen^ ma», 
thighs and legt. Haa eziited linoe birth. No eoiema, 
impetigo, erythema, or ortioaria. Very irritable. 

Cabx 16. — M., ffit. 7 months. Angnit. La^e pale diaorete 
papnlea, chiefly npon the tronk. Four months daratiou. 
Very irritable. 

Caai 17.— 'H., kL, IB months. Hay. Bather small 
papiilea, scattered over abdomen, back, and arms. Mneh 
urticaria, which was more prominent than the prurigo j and 
papular eczema of one arm. Appeared a fortnight before with 
the warm weather. A fat, healthy child. No appearance of 
flea bites or other irritaDts. 

There is one fbrm of papnlar dermatitis of whioh we find no 
accwnnt in the earlier works on dermatology — I mean lAekeu 
planiu. 

No one who has seen a well-marked example ot this affaction 
can donbt the acouracy of Mr. Wilson's original description of it. 
The raised, flat patohea — miniature plateaux rather than plains 
— their dull, glistening surface, deep purple-red colour, and the 
frequent marks it leaves behind, are very oharaoteristio. The 
localisation ia not constant. Most frequently, perhaps, the 
back of the hand and wrist are the seat of the disease j soaroely 
less so the leg or thigh, and the patches are not eonfined to the 
extensor surface of the limbs. The trunk is also not nnfre- 
qnently affected. It does not seem to have been observed in 
children. It is usually said to be more frequent in women than 
men, and in thirty cases collected from various sources I fbnnd 
eleven were men and nineteen women; but the numbers are 
too small to be eondusive, and the diffierence too slight to be 
important. It is, however, worth noting that almost all 
Hebra's cases occurred in men. 

As in psoriasis, the amount of itching varies greatly ) some 
patients feel scarcely any irritation, others complain greatly of 
this symptom, and scratch marks or secondary dermatitis some- 
times coniirm their complaints. The course of the affection is 
always chronic. Arsenic and local application of tarry com- 
pounds are sometimes very quickly effioacioas, but I have some- 
times found the cure tedious. 



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Lieken ptmmu. 85S 

I hxn moat often Men Idohen plutiu miitaken tor lyphilo- 



Tbart B»n be no doabt of ths oloM illiuice (illnitrated 
hf one of tha oua giren below) of tUs sffeetion to cniaia 
other fimns of papular dermatitis, eipeciaUy to what Hebra 
dflieribaa aa liohen mbef . The; are both eauDtially papnlar, 
both ehnmie, boA dark, both uritaUej they are somewhat 
dmilar in distribution, and they sometimei oocur together. 
Indeed, Mr. WUson recogniins the eloaa reaemblance or iden- 
titf of his Lichen pUnns with the disease previously described 
by his coUeagne in Vienna, and frankly yielded him the priority. 
Nor can we birly qoestion the relation of Lichen planus to 
paoriasui, which has been to well supported by Mr. Hutchinaon, 
It ii Toy seldom that tbe resemblance is one of appearance or 
distribution ; bnt it depends on the clinical features of dry- 
ness, chnmioity and irritability, tbe common character of solid 
hard papules becoming afterwards scaly, the liability to pig- 
mentation, the readiness to retnm, and the reaction to the same 
therapentio measnrea. All these physiological charaoters point 
to a tme kinship. A case exhibited at the Pathological Society 
by Mr. Morrant Baker, in the session 1880-1, sbowed the 
occasional difficulty of diagnosis between psoriasis and Lichen 

On tbe other band, I woald, at present, separate Lichen 
phmu, and even Lichen ruber, somewhat sharply from other 
so-called speciea of " lichen." Tbe word by itself has come to 
mean little more than a chronic eruption of papules, and 
I doubt whether we can at present use it to any better 
purpose. 

The following cases of Lichen planus seem worthy of being 
put on record. 

Cisi 1. — A man, aged 80, preaented himaelf among the out- 
pstients with eight or nine flat, raised, slightly-soaly red 
pstchei, from a pea to a threepenny-piece in sise, situated on 
the back of the wrists, the forearm, and tbe dorsum of the hand. 
On the right leg there were several similar plaqua, which had 
united, and here there was a good deal of ordinary dermatitis, 

■ Bd Si. DnekwoTth (■ Bt. Buth. Hoap. Bep.,' voL vUl), wbo alto agrsM with 
EU in MgudiBg £4cAm pJowu amd X*piM r»b»r ratlier h olofely allied Uum 



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2S0 Obgervationa on Superficial Dermatitis, 

Bet up by scratching. The eruption had lasted three months, 
and had never appeared before. Next week he came with a 
fresh crop of scattered papnles upon the inside of the left 
thigh. He was ordered Fowler's solution, but disappeared 
before he was cured. 

Case 2. — ^A ladj, aged about 45, came to me, having been 
previously treated with mercury for what was supposed to be a 
syphilitic eruption. For three months she has noticed small 
red patches on her hands and feet, and they have gradually 
increased. They b^au as "pimples," and a few separate 
papules are still present, but the lesion consists chiefiy of raised, 
flat, bright red elevations of the skin, covered with faint indi- 
cations of minute scales. They do not spread, but fresh papules 
appear and coalesce. The parts affected are both hands, on 
the backs, between the lingers, and on the palms ; less so the 
feet, including the soles. The eruption is very irritable. There 
are two smooth patches inside the cheek and on the dorsum of 
the tongue (psoriasis lingnse). No other lesion ; healthy 
aspect. History of a rash several years ago which affected the 
arms, legs, and waist. The colour and the uniformity of the 
eruption, the irritation, which was decided though not severe, 
the account of a previous eruption which was pretty certainly 
not venereal, and the absence of all other signs of syphilis, 
convinced me that the affection was not of that character, 
notwithstanding the snspicioas localisation and the carious 
coincidence with an affection of the tongue, which is often 
mistaken for a specific lesion. I accordingly prescribed five 
drops of Fowler's solution three times a day and only cold 
cream locally. A week later there was slight irritation of the 
conjunctiva, and the rash was much improved, paler, and no 
longer irritable; while no firesh papules had appeared. But 
aft^ another week fresh spots with fresh irritation were ob- 
served on the forearm and at the bend of the elbow. Somewhat 
later the same papnlar eruption affected the legs and abdomen, 
and was accompanied by great itching. The patient, however, 
persevered in the use of arsenic, to which I had added Liqaor 
Carbonis Detergens as an ointment (^ij to the ounce of vaseline), 
and wrote to me from the country, in October, that she had 
lately improved. The final result I have not been able to 
ascertain. 



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Lichen plataa. 257 

Ciix 3. — ^A very BimUar case to this last OBe is the foUowiog : 
—A stoat, heaUhy-looking vaman of fiity-thne cune to the 
hospital with a chronic lichecoiiB ernptioD on the back of tha 
hands, the forearms, upper arms, hams, and thighs. Besides 
ptpnles, there 7ere the flat^ smooth-topped, scaly, raised patches 
of Lichen planns, and here aod there the scales were so mnch 
developed, and the affected sarface so large, that the case looked 
like psorissis. There -vere flat, smooth patches on the tongue 
and cheeks (psoriasis lingn«), bat no sign of syphilis. Similar 
treatment, by arsenic internally and tar ointment locally, 
tucceeded mnch better than in the former case. Macula 
remained after the cure was complete, 

Cass 4. — A case, of which I have only a short note, occurred 
in a woman of thirty-eight, who came among my out-patients 
^th " Lichen ruber, papulatus et planus " affecting both fore- 
arms and wrists on the flexor side. Colour dark red, smooth 
Eoriace, irritable. The affisction had lasted three months, and 
had never occnrred before. I treated it in the same way as the 
lut, bat did not learn the effect. 

Cui 5. — A remarkably strong, large>framed labourer, 
35 years old, came with four well-marked patches of lichen 
pianos on the back below the angle of the left scapula and 
tomewhat lower down on the right flank, and on the flexor sur- 
face of the right forearm. There were papules, separate as well 
aa coalesced into the raised plagues. The colour was a dark 
purplish red, the surface glistening and covered with small, 
fine scales. In a few weeks, under tar ointment locally and 
anenical solution, increased to eight drops three times a day, 
internally, the eruption disappeared, leaving decided pigmentary 
stains behind. 

Case 6. — A patient of mine, suffering irom mitral insuffici- 
ency as the resalt of rheumatism, an otherwise healthy young 
nan, somewhat under thirty, showed me an eruption which he 
Wspected to be syphilitic, although he had never had a chancre. 
It had lasted several months. There were scattered papules on 
both legs, some of them covered with small scales, and patches 
looking like psoriatis nwnmulata. The colour was a deep red. 
There was great itching. The knee-caps were free, the parta 
affected being the shin, calf, bam, and adjacent part of thigh. 
The arms were also &ee. I ordered Liquor arseniodis, five 

TOl. MT. 17 .-. , 



ASS Obtervationt on Bvperfieiol Dermatitit. 

nuDUDB Bfter each meal. There was aome old, iry, ehiOnic 
dermatitia of the hands, the remaiaa of what ia former ytara 
seemed to have been ordinary eczema. A few weeks Ihter th< 
patches were more distincUy raiBed, flat, Bhiningi and fiusredi 
and the scales more scan^ and miante. As Fowler's aritatimi 
produced disturbance of the stomach, I now order^ fire drt))M 
of Liquor Sode Arseniatia three times a day^ with peiMveteBrt 
in the use of the ointment. When the smell of this last becamA 
insupportable to the patient, I substituted a strong oi&tment ni 
Liquor Carbonis Detergeas (siv to 5) of vaseline] , and increaaed 
the dose of Pearson's solution to seven minims three tinea a 
day. The eruption bad been steadily fiading, no &toh spots 
appeared, and the cure was complete in abont eight wetks ; 
slight pigment stains were left behind. 

Casx 7. — ^A man, aged 21, but looking <dder, vi^aA com- 
plexion and strongly built, came as an ont-patien^ witii itha- 
racteristic Lichen ruber and Lichen planus aSeAting the fkee^ 
chest, back, and trunk generally, as ps^nles f and the riboWSt 
forearms, and thighs, as raised, flat patches. The colost w«s 
dark, but not coppery; itching ndt severe. He recovered 
under treatment with tar ointment And moderate dooea <af 
arsenic.^ 



y. DsRHATITlB EXFOLIATIVA. PtTTRIABlS RCBKA. 

The species of Pityriasis as defined by Bateman are none of 
them entitled to permanence. P. eapitu or dandriff is in most 
cases seborrhoea sicca, in others a slight local dermatitis ; an 
eczema a<|uamoBum, often (as he remarks) due to want «f clean- 
linesB, and removable by soap and water, but apt, if neglected, 

■ I may T«fer student* dt thti remarkable Tonn of JtiiMiA tit 'ibi ^oObw^of; 
(leacriptiom and csHt:— WiltOn, * IMieMea of tUe ain,'6tb ed., iSfl?, p. !UUt 
HUller, Tilbury Fob, ' Biit. Med. Jovrn.,' AprH, un, and In Mi < Teit-b«oK> 
p.lMt HiltonFttgKe,iiiToLzT,of tbepivMntMrietofOiMa BtpnHj^SUf 
Uyang, ' Eand-lxNik,' ZaA ed., p. 189 ; HntehtiMoii, ■ Lectniw on Qiidol 
Snrger;,' p. 207. Dr. B, W. T«jlor, of Kew "iaik, bu pnbliibad fanr einf olbr 
obmred cuei of th« dinaie in tbe latvoL of tlM 'AroblTei of Dtirrnktalogy/ 
which (how tbat its tMtorea in Amerioa ruemMe Un bgUih ilhilN ^tSW 
two moteU of it 1b ou Ubnb&i, No. an. S60. 



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Pifyriatit rubra, 259 

" to d^enermte into Porrigo/' I. e. to become piutalar. Oeea- 
riontUy it is Fsoriaau of the scalp, the scales being small and 
mixed with sebum oving to the locality. P. versicolor u a 
parasitic diaeaae. P. niffra, obserred b; Willaa in children 
born ia India, was not identified by Bateman, nor I believe 
nnce. A case of AHberfs, which Devergie calls Pityriasis nigra 
with pmrigo, was apparentlj Froiigo pedicularis with pigmen* 
tation and lencodermia. '^e fourth and last species, P. nU>ra, 
"resembling Psoriasis difFnsa," denotes like it a stage in the 
involntion of ecsema. P. rubra of Caienave seems to be only 
P. vertieolor with more irritation than nsaal. 

The word Pityriasis denotes, as its etiology implies, a branny, 
forfaraceona desqaamation ; and if we continue to nse the term 
it is only as " roseola," " erythema," or " herpes " to denote a 
certain anatomical condition, without deciding npon its canse 
CT predietigg the event. 

Bnt the speofic term, Pimuun sTn»&, ii bow nnd no 
kmger to denote s«di desqaamatioii occotring on a red skin, 
as IB ecKma or scarlatina, bat to signify a «nbsrtanti*e disease. 
This apidieatioB was made by Dem^e in 1864. In his ' TraiM 
pra tiq tte des MalacHea de la Pean,' p. 268, we read : — " Pitt- 
uasib mtn&a. — Je place eiipris de VeoetmiL I'hiitoire de ortta 
nabtfie, )l csaw des ctiffieoH^ de diagDostie qn'elle pr^sente, 
et de sa gnmde anak^e de fonne avec eette affection." 

He describes the disease as banning with an erythematosa 
ndness, vn^y en the cheat or flexor sorfaoe of the linhsj and 
spreadiBg rapidly, with a weil-defined margin, deep eohmr, 
tbimdant aeales, nnd more or leas thin serons dischai^. It 
coren the whole body,^ is very tybrtmate, lasting for monfta, 
and occRraonally proves fatal by eshaiutioD and diarrheea. Aa 
a rate.howerer, patients aloiriy recover. Relapses are freqnest, 
Derergie admits the JtiiBealty of JistiagTWshing this new diseae e 
from edema, and bases the diagBosia ob ^e fcdlowing pmnta, 
vhidi I t91 pat in -a tabohv form, 

■ 'CtA IiMiile ^fffiii"" qtiiiATM le pforikdi aign, pnuH envfthir i lifok 
tooU h nif Me da U pMD de llionime " (loc at^ p. 864). 



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260 Observaliont on SSuper/ieial Dermatitit. 

Eczema. Pityriaiit mftra. 

Bright red colour. Rongeur fonc^. 

Border ill defined. Sharplr-marked border. 

Ib neTer universal. May affect the whole akio.^ 

The akin u not thickened. The ekin, and even the sab- 

cutaneous fascia are thickened. 

Itching aerere. Less itching, more bnroing. 

Secretion stiffens linen. Secretion thin, and does not 

stiffen linen. 

Scales small, adherent, and Scales abundant, readily de- 
only form during involution. tached, and present from the 
first. 

fitat pODCtu^ No red secreting pomti 

under the scales. 

DeTergieadds:-~"Cettemaladiene semoutre guSre que vers 
I'ftge de qnarante & quarante-cinq ans. ... on I'obBerre plus 
■oavent chez la femme que ches I'homme." He ends bis 
account of the dueaae by giving two cases in which " pityriasis 
rubra se transforma en pemphigus." The description of these 
cases resembles that of the Pemphigus foliaceus of Cazenave 
(which is not mentioned by Devergie, though it had been shortly 
before described and figured), but it does not appear that any 
bullre formed, only a thick " mucous " liquid of faint fetid 
odour was secreted under the scales. One of these patients 
was a woman of aixty-one, who recovered ; the other a man of 
fifty-two, who was still under treatment when the report was . 
made, eight months after his admission to St. Louis, and five 
years after the beginning of the disease. 

Dr. McQ-hie narrated, nnder the title "Htyriasia rubra 
acnta,! a rare form of skin disease," a case which he rightly 
regarded as coming under the description given by Devergie 
(' Glasgow Medical Journal ' for January, 1858, p. 421). This 
was, I believe the first published in this country, and intervened 
between Devergie's work and those by Hebra and by Wilson. 
The case ^as in a young man *. it began with ordinary vesicnlar 
eczema of the elbow, rapidly spread as a dry red desquamating 
dermatitis to the whole body, and ended in recovery in rather more 

' It miut be obtorred that ofSDh to wUcli Hebi* tftarwud* took « 
nten to the onMt oot to tbe dnntion of the rli>oiio. AU Devetgie*! eum 
ohrooic 

D„tM,Googlt' 



PUyrioiu nAra. 261 

than three months. The desquamation was branny (pityriasis 
ia the literal seose), and there was some pyrexia. Dr. McGhie 
carefully distinguishes his case from ecsema and from psoriasis. 

This same patient was bronght forward by Professor Q-airdner, 
of Glasgow, seventeen years later (' British Medical Joomal/ 
March 13th, 1875). He had suffered repeatedly from returns 
of the same disease, each lasting for some months and affecting 
the nails as well as the skin. In the last attack, from October, 
1874, to February, 1875, the temperature was found to vary 
from a little under 100° up to 108-8°. 

In the first volume of his ' Hautkraukheiten ' (1860), Hebra 
adopts the term of Pityriasis rubra in Devergie's sense. His 
description, based upon three cases, agrees essentially with that 
just given, and he especially lays stress on the universality of 
the disease, its remarkable red colour, its great obstinacy, the 
dryness and desquamation, and the absence of itching. On 
three points, however, Hebra's account differs from that of 
Derergie. He makes infiltration of the skin the characteristic 
sign of chronic eczema rabmm, and its absence the peculiarity 
of pityriasis rubra. Instead of an abundant formation of large, 
thin, easily detached scales, Hebra speaks oi gam unbedeuiende 
Sehi^penraengen ; and again of geringe Schuppenbilduttg, ganx 
vnbedeuteade Abtchuppung. He omits all mention of moisture. 
Moreover, in his experienee the prognosis was more unfavour- 
able than in Devergie's; for the three cases be had observed all 
died. In his table of diagnostic points be contrasts the mois- 
ture of eczema with the dry scales of P. rubra, the papules of 
eczema with their absence in F. ntbra, and the irritability of 
eczema with the constitutional symptoms of P. rubra. 

The discrepancies in the acconnts of these two eminent 
observers show the difficulty of making positive and conclusive 
statements from a small number of cases, for there can be no 
doubt that Devei^e's and Hebra's cases were both distinct 
A^m eczema and both examples of the same disease. Further 
experience has shown (in Vienna as well as elsewhere) that the 
Pityriasis mbra is far from constantly fatal. Infiltration of 
theskin is not an invariable character of either eozema or Pity- 
riasis rubra, but I have certainly found it present in almost 
every case of chronic eczema, and much less marked, or absent, 
in those of Pityriasis rubra which I have seen. 

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363 Ob$ervalumM on BuperfieUU Dematitit. 

How Hfibra can have made bo little of tho abnndant detqna. 
mation can only, I think, be explained hj the eSbcts of hit 
treatment : lokeirarm baths continaed for honn and the nu of 
toftening ointments, " Teronachten insofeme eine Veraender- 
nng, weil dadnrch die Epidermismasaen (so the Sehappenbil- 
dung mnst have been oonsiderable) trantparenter and die Hut 
geschmiediger wnrde." 

In 1861 Dr. Wilks described, in the seventh Tolums 
of the present smes of these ' Reports,' a case of " Qeneral 
Dermatitia," acute, universal, red, dry, and scaly, the desqu- 
mation being very abundant and inclnding the finger- and tiw- 
□ule. It lasted two months, and ended in complete reeorery . 

In 1867 Mr. Erasmus 'Wilson described three cases, whicfa 
he identified with the Pityriasis rubra of Hebra, and proposed 
the names Ecsema foliacenm. Pityriasis foliacea, or Rtyriaiii 
foliacea rubra. 

The second case, termed Psoriasis squamosa rubra (paoritrii 
in Mr. Wilson's language meaning at that time dry scsly 
ecEema), occurred in an old lady of 71 i it was confined to the 
hands, and might be fairly regarded as obstinate ecMins 
mauuum.* But the other two cases, both in old men, are 
typical cases of Pityriasis rubra, in their umversality, redness, 
dryness, and profuse desquamation, as well as in the uniformity 
of the lesion, and the absence of severe irritation and coustitn- 
tioual disturbance. One of these patients died of an attack of 
bronchitis, the other lived to recover of his disease. 

Hebra did not admit that Mr. Wilson's cases were Pityrisn* 
rubra in his sense of the word. The chief points of di£brene« 
are in the scanty desquamation and the ill end of the tiuee 
cases observed in Vienna, Dr. Hans von Hebra has, however, 
since published three oases (1876), which were preaamab^ 

■ He obrtliia^ of tha dliau* U sttMtcd ud poMib^ wphiBsd ^ O* faOf 
Ing lUt of remediM glvan withont nooMi during tao nmt^i — An siwi eil 
oooTie of thra* moiithB t > couw of Donovan'i (olutioD for three weeki ; UeUe- 
ride of merooij for oae month i nitro-mnrialio acid with h bitter ; nmU dMM ef 
■nlphate of magnesia with qmoiae, with nitnte of potaeh, and with coUienBi 
Iodide of potunnm with ocdehieiim ; dtntte of irai M>d qalsliie i Uqaor liliitiiM 
with ■mmuilj and witb ralphnrio >dd i gmtUn with Kida { wd vuiov W—^*** 
beeidM. Meantime were applied looalljr oxide and c^^l^l^^^^f ^f ain^ ateUte vl 
lead, ammonio-cldaride, nitnte, asd nifaia oxide of vmvarjt tvlpbuTt iodidiV 
caibolio acid, and tar. 



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Pffyriatu rubra. 368 

mx^lud by his fatlier as genuine pityriuiH rubra. Two 
vere in men; fat one desqn&mation was profiue and in large 
flakes, in the other it was leas abundant ; botb patients died of 
■draaced pfathialsj with tuberculosis of several organs. The 
third case be^an with impetigo of the scalp in a woman of 
64, and agreed in the cbaraeters of aniversality, redness, dryness, 
and desquamation. She left the hospital after two months' 
nniBeeessfnl treatment. Other oases hare since been pub- 
liihed by the late Dr. Hillier, in 1864/ as Pityriasis rubra, and 
by Dr. Fagge in these '"Reports for 1873,'' as " Eczema squam- 
osnm anirersale seu Pityriasis rubra." 

Mr. Wilson in his " Lectures on Eczema" (1870), describes 
the disease at length and gives an additional case. It occurred 
in a young man of 98, and was developed out of an ordinary 
chronic eczema. It showed the characteristic features of 
universality, deep red colour, dryness, absence of itching, and 
profkue exfoliation of large, thin scales, which Mr. Wilson 
compares to dried hops. There was decided infiltration of the 
■kin, and the nails were affected. The disease lasted from 
October to January after an acnte onset ; by the end of three 
' months the patient was entirely free from it. 

In these lectures, Mr. Wilson propoied to substitute the title 
" eifotiative dermatitis," or xczbha ezfoliativdm for pityriasis 
rubra or pityriasis fbliacea. Pityriasis was an ill-chosen word, 
for the desquamation is anything but branny, but the term is 
now established and is distinctive. Moreover, most pathologists 
deny that the disease is eczema, and I think on good grounds. 
The late Dr. Tilbury Fox (writing in 1878),> while agreeing 
with the descriptions of Devergie, Hebra, and Wilson, not 
only separates Pityriasis rubra altogether from associatioo 
with eczema, but maintains that it is not truly a dermatitis at 
slL Dr. laveing,* on the other hand, agrees with Dr. Fagge in 
r^arding it as only a peculiar form of eczema. He admits 
ttie ■Ibseiiee of vimble exadation, but has found traces of it on 
the under surface of the large thin scales. He also describes 
the cntis as not thickened by inflammatory InSItration. In two 

' ' Budbook of Skia DiiMiM,' p. ;01. 

' ' Qv-ft Socpital Bepoit^' 8rd leriM, toL xiiL 

• ' Sfcin DiuuM,' p. KZ. 

* I Hinabook of the pikgnoili of Bkiu DImum,' p. 89 (1S78). 



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264 Obttrvatioiu on Superficial Dermalilis. 

cues he hid obaerred albaminariB. One of the p&tiesti 
reoorered, the other died of chronic Brighf a diieue. In a 
third CMC, under Dr. Hcnrj Tbompaon, Uiere waa no albfl- 
minurU; bnt the patient diod^ and poti mortem, no organio 
diseaae w«8 diacorcred. 

Ur. Hutchinoon, in the following year (1879)j pnblialied 
three most intereating lectnrea on Pityriaaia mbra.' He 
admita that the abaence of liqnid ezadation and of thickening 
of the akin diatinguiafa it anatomically from ecsema, bnt 
r^ards ita eaaential featnrea aa univerBality and reaistaace to 
treatment. He would therefore regard it aa a type of a group 
of affectioos diffeiing in their anatomical featnrea aud includ- 
ing " Femphigna foliacena, certain rare caaes of diSuae eestxat 
and paoriasis, which end fatally, aome forma of aenile paonasii 
palmaria, aome of onychitis, and some of lichen paoriaatt" 
(t.0. Lichen pianos and rubra). Aa to the pathology of thii 
group, Mr. Hutcfainaon compares them with genorsliied 
destroctiTe inflammation of the jointa, and thinka that like 
that condition they will prove to depend on a nenroaia. He 
u^es that their aymmetry and amveraajity are condusiTe 
against Pityriaais rubra and its allies having a local origin. 
"We have therefore to choose between the blood and tlie 
nervooB ayatem, and in the entire absence of any proof of 
implication of the former I prefer to suapect the apinil 
cord." To my mind, I confeas Pityriaaia rubra ia aymmetrical 
becanae it is unireraal, and is uairersal becanae the akia a 
oniTersal. The universality is no doubt an important feature of 
the diseaae, bnt it belonga also to Ichthyosis, which is totally 
different in its natural history no less than its anatomy. 
Moreover, eczema may be more nearly universal than many 
audoubted cases of Fityiiasis rubra without losing its chsracten 
of ecEema. The resistance to treatment is another important 
feature, but this also applies to several other diseases of the 
skin which have uo other bond of union. And reference to 
the table at the end of this paper will show that most of 
the cases recorded have recovered, and that many have in the 
judgment of the recorders been cured by treatment. 

Aa to the pathology of Pityriasis rubra, in the absence (as it 

seems to me) of any proof of implication of the blood or the 

' ' IieotDTM on CUoioa Snigwy,' pp. 840—274, 

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Pityriatit rubra. 266 

nerves, I prefer to snapect the skin. For whaterer else the 
diseue ma; be, it is certainly a dennatitiB ; and there geemi 
to be no reaaon why the living cells of the skin shonld not be 
liable to idiopathic inflammatioa as much as those of the 
mncons membranes, the kidneys, or the longs. Beside the 
clinical evidence we have also histological facts proving that 
FityriasiB rubra is a tme dermatitis, which have been observed 
independently in Vienna and in London. 

A microscopic investigation of the skin made by Dr. Hans 
Ton Hebra showed that id a fatal case of the disease, which had 
lasted a year, the whole of the catis, papillte, and deep layer, 
with part of the anbcutaneons iascia, was filled with leucocytes. 
In the other fatal case, which had lasted several years, the con- 
dition was very diSereut ; it resembled cicatricial tissue. The 
Ualpighian layer of epidermis was thin, and its cells shrunken ; 
the papilhe were also atrophied, and only few remained ; the 
psirillary layer was represented by a thin layer of connective 
tissue, under which a thick layer of yellowish-brown elastic 
fibres with abundant granular pigment represented the deep 
layer of the cutis. No sweat glands could be found, and bat 
few sebaceoQs glands.^ 

In the same year (1879) in which Mr. Hutchinson's lectures 
were published Dr. Buchanan Baxter published a valuable 
paper ou the subject in the ' British Medical Journal ' for July 
19th, under the title "General Exfoliative Dermatitis." He 
details five cases. 

The first was a universal dull, red, dry eruption, with infiltrated 
skin and profuse desquamation, and occurred in a little girl, six 
years old — a truly acute case, running its course in less than 
two months, with albuminuria and moderate pyrexia, and 
proving fatal by indema of the lungs and diarrhoea. Beyond 
chronic peritoneal adhesions and bronchial flux, with emphy> 
sema and cedema, no lesion was found after death. The kidneys 
are not mentioned, and therefore we may assume they were not 
the subject of Brighfs disease. Sections made of the skin showed 
alight swelling of the papiUse and enormous thickeniuff of the 
cuticla, while the Malpighian layer, instead of being sharply- 
defined from the latter, passed very gradually into it, the inter- 
mediate "granular layer" of epidermis having disappeared. 

' I quote tbii iccount from a report in Behrend't ' Haatknmkluitao.' 18!V< 



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368 Obiervatumi •» Super^Mml DermatUu. 

1h» seoond of Dr. Baxtai'i suet ooenxrod in ta isfut ux 
moBtlis old irbo, ^ffeur tttffiari&g Mmral weeks flroqi ordjniry 
eweiQlt of the head and ftuw, vks attacked with nnmnal der> 
matiti) of a dull red eolonr, iry, and pvodndnf ^biuidut laiga 
thiit wnlet. It piaved fatal in eight «eek». 

The tbird caea vaa in a woman, aged twenty-eight. It pie* 
■ested tbe eharaetariatui featorca of Pi^riaaia rubra, and emdod 
faroorably after a coarae of between two and tbra^ Bon^, 

Tbe foortb waa a remarkable one. It ooBurred in a hey of 
aoven, and wai at firat regarded aa Liehen ruber i aa it grade- 
4lly ipread over tbe whole body it aaaumed rather the aharaatcn 
of an " aoQte paoriaaia," bat en the whole Dr. Baxtef mganb 
it aa belonging to tbe aariea of Ktyriaaii mbra e* genenl 
exfoliatiTO dermatitii. NotwithstaQding ita wide diffiuisa, 
dryneai, and profme desqnamakion, the faet that aoma paiti of 
the body appear to hare eaoaped, and tbe pveaenoe of pvqbi, 
appear to me to be important polnta of difhranee. AAe> thiaa 
montba' treatment (began tbreo waoka after the appaaraaee ef 
tbe diaeaae) by warm batba, with avaonie and eod-liver oQ 
intaroally, the eruption bad diiappaared, bat the boy waiwoak 
and thin,and died a few weeks afterwarda from aome aente&biila 
afieotion. Tboro had been no albumiunrla doriijg hia illnen. 

Dr. BaxteHa lul ease waa one of pemphigaa (apparently »** 
•yphilitii:} oomiag on ten daya after birth, wbieh paaaed into 
general iry eifoliatiTa dermatitla. The inhnt raeorered in two 
or three weeks under arsenic. This, Dr. Baxter lays, wonld 
probably be eaUed a eaae of Pemphigaa fbliaoaBaj bat he 
ai^aes for the reoognition of general ezfbliative danntti^ as a 
oommoa meeting point of tbe four '< dartaona " or berpetie dk* 
orders wbiflh are durable by arsanie, via. Beiema, Koriau^ 
Ijioben, and Femphigiu, wbenaror th^ beeone auivanal. 

lite objectioiii to tbia ingenioaa hypothaaia eaem to me toba 
the following: 

1. Boaema ia ita wdinary meiat ferm m^ he uivwaal or, 
at leaat, aa nearly ao aa many of the eaaea whidi Dr. B»ter 
would iiwladei witho^ abanging ita eharaeter, and may n 
continue for jean without either the pepoUar anatmnieal itoee. 
tore pr tbe phyaiologioal eOeeta whidi cbaraoterise the typieal 
casea of ''gweral HfoUatiTe dsrmatitiBi iribiaaa my eaae i> a 
lad vbo lud anOeied tiw» Inrtti ten enMiiM (p. 316) . 



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PUyriaait rubra. 267 

9. l%cnigh few, tf uy of UB, in Bngland hftre Hen r eaM 
(^ nnivenkl knd ehronie Liob«n mbw u Helin doMribsd it, yet 
he earefnUy, uid appuently with jottlce, dutingniahed it from 
ntyriuiB mbm. 

8. We m»7 find the diapBotertstie anatomieal ohaneten of 
ofidiBtiTe dermatitlB or " Eoeema Miaoeum/' not aa a univenal 
bttt ai m loeal aiiMtlon. Of thia I ahall gire Bereral examplea 
pTCMntly (p. S78). 

4. PerapblgOB fbllacene is not ever, 1 believe, nniTeraal ; it 
is almost limited to women j and ita obstinaey and the eon- 
ddenble and often ftetld disoharge explain ita eoutltntional 
eflbetB ; vhereaa some of the mott marked oaaea of Ktjrlaaia 
rnhra, free from irritation, and almoat from apparent inflan^ 
station of the skin, are jet prodnctire of grave internal efibota. 

5. That the whole of the akin may be oooapied by a thick 
Maly diiraan without Intarferenoe with health ia proved by 
aany easea of lahthyoais. I have now tinder my care, in 
Miiiam Ward, a ehild whoae entire akin, from head to foot, 
iaduding the palma and solea and acalp, ia occapied by the 
aererest form of lohthyoais cornea j and ahe aaffen greatly 
from itehlng. Yet ahe haa an excellent appetite, sleepa well, 
■nd ia fht and firm in flesh. The orine ia free from albomen 
aod, in fact, ahe is not " bodily ill " at all. 

The aonrse of opinion upon the nature and limita of Vitj- 
fiaaia rubra haa been even more divergent in France than in 
England, lome dermatologiaia accept Devergi«*B term in 
nearly his meaning. Banu wrltea of a " Pityriaais rubra aigne 
ftnin^Ue qui a'^nd k la presqne totality du oorpa,'' and the 
ahendant e^oliation of large toalea which be deacribes oon- 
flms the belief that thia is Devergie's, Hebra's ud Wilson's 
dlaaaae j bnt he also deaciibeB a " Herp^tide exfoliatriee," and 
the ease so named by M. Ooiboat (No. 19 in the table at the 
end of this paper) b certainly one tf Pltyriasia mbra. Hardy 
deaeribe^ PltyitaaU rubra in Willan'a, or rather, perhaps, in 
Caienave^a, senae of the term, as a branny desquamation on a 
led skin, commonly oceapyisg the head and neck, bnt " qnel- 
qneisia tonte la aurfroe da eorpe." Qeneval symptoms not 
onfreqaflBtly aeoompany it, eapaeially fever and digestive 
Tbaae last two ahamoters recall Devergie's 
* ' Ltfowi' p. IM. 



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fro ObiervatUmt m Smptrfidtd DermatUU. 

begimung to heal hg deaqasnMtum, Thflre ii aam no moutsre 
•ofwhctfl, and thfl patient •mant me that tlwra never hM 
beai» eraa ftt the flanres of tba jants. Thare u aboadut 
^L&iliatMii of au^i whiter bnauf aoa]«% but wne «f tlM 
laijge, thi&t kop-Uke a^aatafli mob lad daMrihtd u mat 
OBBcik. Thfl Amed white edgw i^ axfotiatiBa, wMipand bf 
Mr. WiUoB to fiiUs, to aoak •raoor^ aad to Cbe xibbad nad 
oa tke Bhoroi are wsU ttailadt 1^ ikiu k net toi; pun- 
fult and lew initkblfl tbaa ona weald wuffout. T^ adov m 
a fall, iHrigh^ "i^aBuoateif " Ndaea^ wi^oat lividi^ or tfaa 
slighteat pigneat&tkMk The vurioaa ergasf tffetx to ks 
normal, and the mine ia free irom albumen. XJm patiaat t»f» 
tbat ha gmeral faealth ia very jpiod* eio^ wban ttia anption 
baa reoedod, aa it ^d batweau tha agM of airtean aad t««t;f> 
eight. No traateant bad a defliain ijba^ aad ahe left tht 
hoa^tal ID 2f V booIi as aha oama in. 

Case S. — General exfotiativt deimmtitiBt tmik firm eCMM- 
tout teereUoHi «wte ceyw*,- <fliM»iaM ff ia ; nata aif .— A wanan, 
»t. 26, waa trasalarrad to ay «ai« by I>r, Oalabia u Ootoha^ 
187ft, with getter^ aonta denaatitk. The faUowing it a 
aummarf of the caae4 

Abb S— > aaffaring from petrit «UaUtiB» «M ftMack«d wUk 
in tiie ward with • paynlax; meaala Bha eadi on iht trai^ aid 
l^a, acownpaniMl witbalight «0iw-thvaaft aiMl raiaid toMpar * t«w> 
Two daya bter, the tanpentwa roae to 104°, feMd rilw* 
^pear«d intiiearina. TheiaahwaaMlttalliataf actttatiM^ 
measlea, or rubeola; aor waa the alato of tiie toagn^ tlma^ 
or Other ongans, like that in ««f of theae mraaJhreii It had 
Bpread orer the whole body electing 'Ae pihaii ami aoles in a 
week, reaidei apfctcteA on A» cbaat> bolha, oa tlie anm aal 
legs, and a raw weepiag patch bebtad oae ear. Xhne waika 
from the first appcaraace «f the rash, the farerand alliiMiiwiii 
had diaa^ipeuwd, and free deaqaaaiatioB waa goii^ <» ; Iweeiij, 
like pi^riaais, on the aoalp and &oe, in iargt Aaka on ^ 
handa. Impebigioem craats had formed «■ the cbn aad «■ 
the limba, and there waa profuse aeroas aBCraiiim ftooa Aha 
ears, neok, and anas. As iavoUition went «b, tb fKtmm 
pain waa anooeeded by iatolerable itching, wUcfc gra^aaBy 
alio diHHKieaKed. Aa abaoesi fenaed in one udla; aad a 
frerik tmpalar ernpttm appeared oa the oheat aal limbs oa 

D,91,zecl.yGOOglf 



PUgruuia rubra, Sit\ 

tha 6th of December} wbieb oalf luted thrss da;*. The 
|»tieiit wu diiohufed pMfeetly w^ on tha Uit d»j of ih» 
fear, 

l^u CSM reiemblea that of Di^ WUki* rrfenvd to abore 
(p. S62)t and abo ^a whioh I {laUished u A» twsatf-third 
toIdbib of tfaia Series (1877). That wan an aeats naiTenal* 
veaiculac^ aad ire«4>iBgt hat alao detqaaoiatirei damatitU with 
pyrexia, ooeiirriBg ia a patient who vu ^e aatjeot of chro&ie 
tsbolar aqihritUt It ibb an acata aonna and praved fatal in 
fonr da^B. 

CUsi 3. — Opurat et^fbUtUtve i le rmmtitU^ biginititig om reewr- 
remt eotemof frtflut 4etftumatio% f tMl^timgt aatte eourtet 
atbtmitmria i recovcryv — SHmi J) — , «eti 42^ wat ftdmitted iibder 
wof care iate the olimaal ward iia Joljr) 1H79, {Mawiting tha 
flbuwotcrictic featana Of mnirenal «3[f<i>lifttfT« dematitiat I 
ma; odd ttiat Ih\ Baxter wah ao kind aa to oonm 4own to aea 
thia eaa^ and Mtcitel^ agreed ia t^e diafaeaiat Her aoeouat 
was titat i« ^er tw* last pretnaaeies abe hiad anffered froaa a 
Bli|;ht en^tiM on the f«et> and that this hu s^ad durii^ the 
last tht«a fean to the rest ef the body. The wh«le of the s«f> 
ftee (exeept ^c sBalp and faee)^ both trash and tiaaba, i^olvdin^ 
the pains and aMest waa torered with « dwfc^ redt seal; eniptfoB. 
There ireie « fcw large aeattered vesielea and eome peteehiih 
Here and there laeht waeping ^Ots ware to be fonad ; bat tha 
■Ar&ee was geaehiUy 4tf. The aealas ««m large, thin, not 
imbricated and notadherCmt^ EUtdwM«iMBtiauMUf shed in great 
flakes whidi filled the bed. There was aodente pyrexia ; waA 
not Old; albnaieii in the urine, bat also pns and mucos with 
other synptome of cyatitia. For a tune she waa esoeedin^y illj 
hat f^tAmilj and alawly iBpfored^ tha aealefl becaEafe lesa 
- abandant^ the redness Hmfpekni^ tbe «rine becane nemialt 
and she <iftaii oat wril at Hbe and ef AfngwU. 

There was thea«iilf iriight -oidinhEy "diy aoriy eea c Mfc " <m 
the vpper litnba, 

Km «aBW M me d ia fc g tiia foUotring Ootoher «>d Noreknbar 
with ^ne ■wpot ^ aliM ^si s teat Ainnalitis on the flexor aspect 
of the left 4t*eanB jast above t^ wriat. Vfab pretentod m 
ofa&raoteriatic featana axoept its abaAwey, -and tbe fact that it 
prodnoed Btiperfioial ntcnatien, so that ali^ sears remaiMd 
after aha mfe fhiaUy oared. 



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272 Oluervatioiu on S^erfieial DermatiHs. 

The following caaee thov tliat tlie same anatomical condition 
whicli IB seen in general desquamative dermatitis or " Eczemi 
fotiaceam onlTersala '* (as distinguished &om the perfectly dry 
cases of " pi^riasis rubra "} may also occur as a local aBFectioD. 

I. A big florid woman of 44, came among my out-patients 
with somewhat extensive inflammation of the skin. It liad 
lasted for two years. She had not before snflered from any> 
thing like it, and said that she was always perfectly wdl. 
There was no evidence of gout. Both legs were covered with 
large, thin, coherent flakes of epidermis, yeUowish-white in 
colour, not closely adherent to the skin beneath, and when 
removed, leaving a dry, red, somewhat tender surface, like that 
of psoriasis. The affection was not confined to the flexor ot 
extensor surface, covered both hams and extended in a len 
severe degree to the thighs, nates, and abdomen. On the out- 
side of both arms a similar condition was observed, but it was 
less marked,and occurred in patches instead of being continuous. 
There was not much itching or pain, there had never been any 
weeping, and the skin was not infiltrated. A week later, after 
the application of an ointment containing two drachms of 
Liquor Carbonis Detei^ns to an ounce of lard, there was active 
ordinary exudative dermatitis set up (traumatic eczema], A 
superficial ulcer formed on one leg below the calf and there 
was considerable pain and disturbance. Gradually the acute 
symptoms thus produced subsided, and under treatment by 
alkalies and saline laxatives, with lead and zinc ointment exter- 
nally, the skin recovered. After two or three month's obser- 
vation, the patient was so nearly well that she ceased to attend. 
The treatment I here adopted had a more severe effect than I 
intended, but it appears to have acted as we often aee stimulant 
applications' prove useful ; by substituting a more acute ordi- 
nary traumatic inflammation for the previous condition and 
BO leading to the removal of the original disease. 

II. An old man of 76, somewhat pale and thin, but in good 
health for bis age, appeared with a chronic inflammation of 
both legs, which at the first glance looked like eczema, fiat it 
was strictly limited to the parts below the knee, it involved the 
whole of both feet except the soles, where the skin was hard and 
thick; it was dry, and the surface was covered with thin 
epidermic flakes as large as a crown piece and larger. On 

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Pityriaiis rubra. 278 

removing them a very scanty, thick, tenacious secretion was 
found adhering to their deep surface, quite unlike eczematons 
fluid. There were no fiaaures, no ulcers, no varicose veins ; and 
the skin was uniformly affected from a sharp line just below 
each knee downwards. The arms, trunk, and other parts were 
perfectly free from any lesion. There was considerable itching 
bat no other constitutional disturbance. The affection had 
lasted two months. He gradually improved under local treat- 
ment chie&y with Ung. Plumb. Carb., and after several weeks 
was discharged with only a slight ordinary dry dermatitis. 

III. A little pale woman of 40 came with a very simple 
"exfoliative dermatitis" of one leg. She had bee.i under my 
care two years before for psoriasis, which was cured and had 
not returned. The anatomical condition closely resembled that 
last described, but the case was as much less severe than No. 
II as that was than No. I. The patient disappeared from 
observation before the effect of treatment could be ascertained. 

IV. Hannah C — , aet. 11, has attended me on several occa- 
sions in 1879 and 1880 with large patches of inflamed skin on 
both legs above the ankle. The surface is red, angry, very 
irritable, and covered with a scanty, thick, white secretion, 
more like mucus than pus in appearance. This is seen when 
the large flat scales which conceal it are removed. These are 
not scabs, as in eczema, but epidermic scales, much larger and 
thinner than in psoriasis. Under the microscope they consist 
entirely of epithelium, with scanty pus-corpuscles on their under 
surface.' They are easily detached in flakes as large as a crown. 
This patient twice recovered under ordinary local treatment. 

The following two remarkable cases are in accordance with 
what Dr. Baxter baa observed, that a condition regarded by 
competent physicians as. ordinary local psoriasis may assume 
the characters of a more serious and universal, dry, scaly dis- 
ease. Pityriasis rubra. The hereditary character is also worthy 
of note. 

Ellen P — , st. 17, a stunted girl, looking four or five years 
younger^ is still under my care in Miriam Ward. She has 
been more than once in the hospital under Dr. Witks and Dr. 
Moxon,^ sometimes for the disease of her skin, sometimes for 

' Seo Dr. LiTeiug'a ' Handbook,' p. 121, 

° It U Ihii patient to wbom Dr. Moxon refcn ia hit Croonian Lectures. 
VOL, zxv. 18 

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374 ObaervationM on Superfidal Dermaiiiis. 

epilepsy, to irtiicli the has been sabject from the age of ten. 
Once, also, she was attacked with acate plearo-pneomoDia, fcom 
which she oompletely recovered. 

Her bther, brotherB, and sisten have healthy skins, but her 
mother has long been subject to a disease like that of her 
danghter (see the following case). 

She was healthy when bom, bat when eighteen months old 
inflammation appeared behind the ears. This sooD departed, 
but the following year returned and spread to the head and 
neck. Since then she has again and again i-ecovered, and 
again and again the disease has returned with greater obsti- 
nacy. For several years it has been almost aniversal and con> 
stant. In February, 1879, when under Dr. Moxon's care with 
severe epileptic fits, the whole body was covered with a diy, 
scaly eruption, there was moderate pyrexia, but no albuminuria, 
and she went out mnch improved. 

When she came under my care last April, the whole hod; 
was covered with a dry scaly eruption— scalp, face, tmnk, snd 
limbs, incloding the palms and soles. The skin was red, bat 
there was no moisture, and scarcely any fissures, nor were the 
integuments infiltrated or thickened except by the masses of 
epidermis. Those on the scalp were small, and mixed with 
sebum ; on the face, back, and trunk generally, they were 
comparatively scanty, the scales being thin, small, and readil; 
detached, a true pityriasis. On the limbs this branny deiqna- 
mation was replaced by a thick encasement of scales, covering 
the knuckles and fingers and toes, as well as the elbows and 
knees. The scales, however, difi'ered from those of ordinuy 
psoriasis in being more opaque, yellowish and dull, smaller and 
less adherent. The nails of both hands and feet were broken 
and deformed. There was no attempt at involution, and con- 
sequently no trace of an annular or gyrate form. The nrine 
was normal. By a diligent use of baths and ointment con- 
stantly applied, the state of the skin was much improved; 
all the scales were removed, and the surface became apparently 
normal, except that it was stilt somewhat red and tender, and 
showed several pigment spots. She went out in this condition. 

Sophia F — , EBt. 48, the mother of the patient whose case Hm 
lieen just described, is now one of my out-patients. She also 
is the subject of a universal, dry, scaly disease, which I think 

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ntyriatU ruira. 376 

aboold be called KtjniBBiB rabn. Other good obunen, hov- 
erer, coniider it and her daughter's diaeaae to be nnniually 
serere and general psoriam. The pathology of the two is cer- 
tainly the aame. In the mother'a caaa there vaa no appear- 
ance of the diaeaie nntil ahe waa nearly forty. A acaly emptioo 
then appeared on both forearms, and thii ^adaallybnt qoicUy 
spread until it corered the whole of the body. At the present 
time there is not a lonnd spot anywhere. Boalp and face, palms 
ud soles, every region is affected. The nails are brittle and 
deformed. There ia not, and nerer has been, any ezadatioo. 
The scales are generally nnmerona, small, loose, and not 
"pearly " in appearance. On the whole, they are not so thick 
M in her daughter. The face is almost free, being only red, 
noooth, and somewhat brawny, and the hands are iu a similar 
state. Only on the limbs are the scalea thickly massed, moat 
BO on tiie elbows, knees, and shins, bnt the distribution is moeh 
leas regolar than in ordinary cases of psoriasis. There are no 
patches or rings. The hur and teeth are &irly good. The 
tongne ia clean and free from disease, the urine not albuminous. 
Tliere is a great deal of irritation, the itching being sometiipea 
intolerable. The patient is thin and weak, and there ia slight 
pyrexia, but she eats well. There is chronic ophthalmia with 
great photophobia. Since the disease became nnivGraal it has 
never disappeared, bnt the condition of the skin is generally 
worse in the autumn. Ointments suit it best, especially 
vaseline. Arsenic she has fisnnd does her no good. 

She has several chUdren beside the one whose case has 
just been given, but no other* of them have any affection of 
the akin. Her father's family were also iree from any 
disease. Her mother, however, was snlject to what she 
believes waa the same disease — a general dry redness and 
Bcalinesa of the skin — as long as she can remember. This, the 
only person affected in that generation of the family, died aged 
forty-ei^t. In the preceding generation the father (grand- 
father of Sophia and great grand&ther of BUen F— ) waa the 
subject of "the aame complaint." He died an old man. 
Farther back the &mily traditions do not go. 

These two cases have considerable resemblaitce to Dr. Fagge's 
of acute general psoriasis proving fatal in a boy ; indeed, the 
model of the face of that patient iu our museum (No. 1161) 

. „Gooj^lf 



376 Observations on Superficial Dermatitis. 

would, I have no doubt, have been labelled pityriasifl rabra by 
Devergie. The difficulty of diagnosis in this case and the two 
preceding ones is not between Pity riaeis rubra and Eczema, but 
between PityriaaiB rubra and Fsoriasis. Indeed, the case of 
the daughter was called psoriasis by some of my colleagues in 
Guy's Hospital, and that of the mother was called pfloriasis at 
an earlier period of the disease by Dr. Payne in St. Thomas's. 
In favour of this view are, I admit, the hereditary transmisrion 
and the occurrence of pigment spots in the girl. Nor can I 
doubt that the mother's case once presented the characters of 
ordinary psoriasis. 

The objections to regarding either of the cases intheir pre- 
sent state as psoriasis are, I submit, the universality of the 
eruption; the want of any selection of the favourite seats of 
psoriasis before it became universal, and of any special pro- 
fusion in the same regions afterwards, together with the fiill 
and complete occupation of parts which it rarely affects ; the 
absence of any attempt at a process of involution like that 
which almost always attends psoriasis, however inveterate; 
the presence of large loose squames in some parts and of branny 
desquamation in others, with the entire absence of the silvery, 
coherent and adherent, imbricated scales of psoriasis ; lastly, 
the resistance to treatment, especially by arsenic. 

Dr. Baxter would solve the difficulty by explaining my two 
cases as he does those of M. Quibout and of Dr. Fagge, to 
be psoriasis assuming the characters of, or developing into, 
Pityriasis rubra. But the cases are not similar. M, Gniboufs 
patient had suffered from ordinary psoriacis for nine years. 
The universal deep redness with profuse exfoliation and severe 
constitutional symptoms which suddenly set in was clearly 
Pityriasis rubra in Devergie and Hebra's sense, notwithstanding 
that it received the odd designation of " Herp6tide maligne 
exfoliatrice." It ran an acute course of six weeks, and then 
left the patient to his psoriasis. In Dr. Fagge's case there 
was no previous psoriasis ; the disease, whatever it was, was the 
same throughout. In my two cases, even supposing that they 
were originally psoriasis, the gradual progress of the disease 
in an unusu^, if not an unprecedented course, has at last 
completely changed its characters. 

Dr. Baxter's hypothesis I take to he that ecsema, paoriaiis, 

D,9z.c.y Google 



Pityriimt rubra. 277 

lichen, and pemphigiiB, show their pathological affinity by a 
commoQ capacity of becoming universal and asBaming Dew and 
unnsnally severe characters ; but that, vhile thns coQvergiDg, 
they in most cases preserve some mark of their origin. Thus 
eczema when generalised, becomes the moist, secreting form of 
unirersal exfoliative dermatitis (exemplified by Nos. 38 and 87 
ia the subjoined table). Fsoriaats preserves its characteristic 
dryness and appears as Pityriasis rubra (in the restricted sense of 
Hebra, Nos. 3 and 4). lichen develops into the severe general 
disease called Lichen rubra by Hebra. Lastly, Pemphigus 
assumes the well-known form described by Cazenave as Pem- 
phigus chronique foliac^, of which he says ; " L'^niptioQ 
s'^tend alors et pent prendre un charact^re de g€n£ralit4 grave." 
To this last form would belong Devergie's two cases of Pityriasis 
rubra (Nos. 1 and 2), "qui se transformaient en pemphigus." 
Such a simplification is higeiiions and attractive. But I do not 
think that it caa be at present accepted. For (1) most of the 
recorded cases of exfoliative dermatitis have begun from noue 
of these four local and ordinary diseases. (2) Others have arisen 
from erythema (No. 26), or from impetigo (No. 34), which 
no one, I believe, supposes to be "dartrous." (3) If we 
allow these four varieties of exfoliative dermatitis, may we not 
with little more extension of terms admit Hebra's prurigo as 
the generalised and inveterate development of infantile prurigo, 
or of the prurigo mitis of adults? (4) As I have already 
pointed oat, universal dermatitis does not always assume the 
lamecharacteristic anatomical features, and does not constantly 
affect the temperature, the urine, or the general health. 

The difficulties of forming a judgment on the several ques- 
tions raised concerning pityriasis rubra are extreme. I hope 
that this paper may contribute to a more extended knowledge 
of the facts upon which, when tested by future and larger 
experience, we may hope to found a sure and final jndgment. 

At present every fresh esse which I have myself met with or 
which has been recorded by others, has added some fresh 
obstacle to making satisfactory generalisations. But I think 
a consideration of the evidence before us will lead us to 
admit the following statements as true. 

1. The characteristic anatomical features of exfoliative 

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S78 Obtervtttioni on 8ig)trfieial DermaiUU. 

dermatitiB preBent tfaemulrea nnder different clinicsl oonditionB. 
They may oocor locaHy (p. 272] or nniversaUy; u a sudden 
acDte attack baviDg a short and &Toiirable ooone (Nos. 82, 
87} ; as a leriea of recurrent acute attacks (Nob. 4, 10, 11) ; or 
as a chronic disease firom the beginuiug (Noa. 8, 24, 86). 

2. The same disease, as jadged by itB rednesB, peculiar form 
of desquamation, and oniTersality, may be perfectly dry through- 
oat, or may be moist here and there in the flexures of the 
joints, or may secrete profusely. 

8. Even when defined by terms made arbitrarily atrait, a 
QoiTerBal, dry, red exfoliative dermatitiB may be accompanied 
by pyrexia or be free irom it ; it may produce terete emaciation, 
01 Imre the patient well-nourished ; the kidneys may " sympa< 
thise " with the diseased int^mnent, or the urine may remain 
healthy. 

4. Instead of being oonfinedj as Devergie thought, to persona 
who have passed the prime of lifie, subsequent observation has 
■hown us that Pityriasis rubra may occur at almost erery age.' 

6. Lastly, the grave prognosis of Severe, made still more 
gloomy by the experience of Hebra, has been altered by the 
record of numerous oases which ended in complete recovery ; 
and (what is more remarkable) of others in which the dis- 
ease persisted incarable and nuchanged for years but without 
seriously affecting the general health. 

All we can at present do is to separate from one another 
such groups of cases as appear to be clinically and patho- 
logically distinct, to look rather to these criteria than to 
anatomical variations in forming onr groups, to bear in mind 
the practical otgects of prognosis and treatment to which 
classification and nomenclature are a means, and to deviate as 
little as possible from the nomenclature most generally recc%- 
nised in civilised countries, and especially frnm that of the 
greatest aathority on the subject, the late Frofeasor Hebra. 

I would therefore separate as distinct from PityriasiB rubra 
the following forms of disease : 

■ The foUowiug an the egei of tiu pstinite sffected witli the more t^ilol 
fonn of pityriuti nibim in the Table bebw i— Under 10^ four cuee, bende a Bttb 
of pemphigne folkaeni(F} In u Inftuit, wluoh I lure not inelnded. Between 
10 end K^ two cmoi. Between 90 snd 40, leren oaiei. Between 40 end 60, ten 
■SMS. , Above 60, flvs ssms. 



Dig t,zec.y Google 



Pitpriati* ru^v. 278 

1. Acute aniTenal dermatitu : a Bomewhst rare fbrm of 
inflammation of the akin, superficial, i.e. affecting the Mal- 
pighiao and papillaiy layers, so as not to leave soars, and 
ordioarj, i,e. such as can be produced at will. It therefore 
resembles eczema in its anatomy, and runs through the same 
stagesj first hyperoimia (the erythematous stage), then secre- 
tion (the weeping stage), usually assuming the appearance of 
Eczema madidena at once, but often showing Tesiclea, and oc- 
caiionally papules or bullte ; lastly desqoamation. Such cases 
are often called acute Eczema, but although idiopathic, super- 
ficial, and "common" dermatitis, they differ in their very 
rapid conrse, in their universal distribntiou, and in the absence 
of recorrence. Moreover, they are naually accompanied with 
pyrexia and general disturbance, and not unfrequently with 
tlbominaria, approaching erysipelas in these respects. The 
prognosis is grave, but recovery is more frequent than death. 
The treatment is unlike that of eczema ; it is essentially oorro> 
boraiU, quinine, atimnlauts, and mineral acids having been 
found most successful, 

2. Cases in which Faoriasis becomes general and inveterate, 
but atill preserves the characteristic form of the scales, the 
absence of exudation, except as the direct result of scratches or 
of cracks of the skin, and at least some trace of the predilec- 
tion for certain regions. The successful treatment by arsenic 
in fitl] and continaons doses shows the true pathology of such 
caaes, but I cannot deny that severe and almost universal 
psoriasis may resist all treatment and lead to death. 

S. Local exfoliative dermatitis, as I have described above 
(p. 272) ; differing from eczema in the abundance and size of 
the acales, in its sharp border, and its independence of the 
ordinary localisation; differing from Pityriasis rubra by not 
being universal. 

4. Pemphigus foliacens, as described by CaeeDave, Hebra, and 
later writers. The few cases which I have seen of this remark- 
able disease occurred in women ; they differed both anatomically 
and clinically from the exfoliative dermatitis as described by 
Wilson, and still more from the Pityriasis rubra of Hebra. 
One was certainly cured by an arsenical course of treatment. 

I would — at least, for the present — classiry as a single 
natural gronp of diseases, caaee which conform to the deacrip- 



.„Gooj^lf 



280 Observations on Superficial Dermattiit. 

tions of Hebra and the three detaOed casea of Mr. Wilson 
(\oa. 8, 9, and 10 in the table). 

The most marked feature ia their nniverBal diatribution, and 
also their rapid and irregular spreading, which is very unlike 
the gradual and, so to say, methodical extension of eczema. 

The characteristic lesion is the production of laif e, thin, 
papery, or hop-like sqnames, unlike the silvery, imbricated, 
tenacioos scales of psoriasis, the small, dirty, irregular scales 
of syphilis, the branny desqnamation of measles or scarlatins, 
and the squamous stage of ordinary eczema. Their profcnon 
and easy detachmeut are also remarkable. 

In the most typical cases the skin is dry throughout, but 
sometimes a certain amount of secretion has been observed, 
apart from accidental cracks or injuries. This may be tbidi 
and gelatinous, or thin and malodorous, but it nerer has the 
stiffening property due to the richness in albumen of eczematous 
secretion, nor is it purulent. 

The irritation is usually greater than in psoriasis, and the 
skin is redder and more burning. 

In the more acute cases, possibly in all if they were observed 
at the OQtsetj there is some pyrexia and general disturbance. 
Albuminuria is rare. If the disease becomes chronic (as is 
most frequently the case) these symptoms usually disappear. 

The prognosis is not what Hebra supposed, and most of the 
cases recover ; but when it has become chronic, pityriasis rubra 
is probably as incurable as ichthyosis. 

The treatment is not satisfactory. Arsenic has failed in 
most cases to be of service. Even when the skin is perfectly 
dry, liquid applications, and especially warm baths, are much 
valued by many of the patients ; but inunction with vaseline, or 
with lead or zinc ointment, made almost liquid by the addition 
of olive oil, is more commonly effectual. Tarry preparations 
are, I believe, ill borne. 



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ON THREE CASES 



•REDTTCTION EN MASSE," 



Bi N. DAVIE8-C0LLET, M.C. 



Tbekb are few condilioDS which cbubb more anxiety to the 
anrgeon, or which tax more severelf the resouTces of his skill, 
than the pereiatence of Bymptoms of atrangulation after the 
retam of a hernia by taxis with or without an operation. 
Daring the 1a§t ten years many anch cases hare occurred to 
me, and various have been the causes which have led to this 
condition. The most frequent baa been the injured state of 
the intestine produced by taxis or long incarceration, and 
unfortunately, but little can be done under such circum- 
stances except to administer opium and trust to the reparative 
powers of nature. In three cases, however, the continuance 
of symptoms of strangulation has been due to the condition 
which hsa been described as " Redaction eu Masse." As 
there arc some points iu each of these cases which seem to me 
peculiar, and as in two o£ them fatal resnlts followed, which 
might perhaps have been avoided by a fuller knowledge and a 
difi'erent mode of operating, I hare thought it desirable to 
place them on record. 

Casi 1. — John W — , tet. 28, a dresser of sheepskins, was 
admitted into Luke Ward, on November 24tb, 1880. For the 

Google 



286 Cases of " Reduction en matte'* 

laat six or seven years he had had a rupture in the right grmo, 
but it had never been large^ and he had not vorn a trass. 

On the 23rd, at 6 a.m., vhile he was at work, the rnptnre 
descended, and gave him paia. He went home and to hed. 
At 12 o'clock he took some medicine, and vomited immediately 
after. At 3 p.m. the rupture was reduced by a medical man 
without the ai<I of chloroform. The pain, however, still coo- 
tinued, and he vomited two or three times in the course of the 
uight. On his way to the hospital he brought up some greeo 
matter. When I saw him soon after his admission he did not 
appear to be in much distress. There had been no passage of 
ffecea or flatus from the rectum since the descent of the ruptuie. 
There was a good deal of pain referred to the vicini^ of the 
umbilicus. No swelling could be seen in the grain, bat the 
parts about the right inguiaal riog gare « greater sense of 
resistance to the finger than on the other side. I could readily 
pass my finger into the inguinal canal, and I thought that I 
could feel something convex and elastic at its upper end. 
Although his symptoms did not appear very urgent, I thought 
it advisable to explore the parts under an wiesthetio. 

Accordingly ether was at once administered. When he vat 
quite unconscious and the abdominal waUs folly relaxed, I 
could feel a swelling deeply placed behind the intenui 
abdominal ring, and above Poupart's ligament. I eatimated 
that its dimensions were from side to side 1| inches, from 
above downwards 1^, and from before backward an inch. I 
made an oblique incision parallel to Poupart's ligament with 
its centre upon the internal ring. After dividing the 
aponeurosis of the external oblique, and some unusually thick 
muscular fibres at the lower edge of the internal obUque, I 
came down upon a membranous expansion, upon which a few 
fibres of the cremaeter could be traced. As soon as I hid 
made a firee incision into this, which I supposed to be the 
transversalis fascia, a hernial sac bulged forwards tbroogh tba 
opening. Go snipping through this a jet of serom came away. 
I then laid it freely open, and found that it contained from %\ 
to S inches of rather empty small intestine, of a pocpliili 
colour. As far as I could ascertain there was no laceratioo in 
any part of the wall of the sac, which was aboomMllj 
thickened. Wheu I tried to insert my Goger within tbo neek 

Dig tizedoy Google 



Gates f>S " Reduction en maite." 287 

of tbe eac, I found that the peritoneum gave way before it, 
and I had to get my dresser to hold the lower extremity of 
iiie sac firm before I could steady its neck sufficiently to divide 
it with the hernia knife. The bowel could now be returned 
readily. The operation was performed with the usual anti- 
wptic precautions. In about three weeks the wound healed, 
sud the patient went out quite well upon January 15tb, 1861. 

From the inTcstigation I made before and during the Dpe< 
r&tion, I come to the conclasioD that the hernia was an 
scqoired one and that the whole or the greater part of the 
uc had been forced by the taxia to leave the inguinal canal, 
in which it bad been enclosed in the sleeve-like process of the 
iBfundibuliform fascia. Having passed up through the internal 
ring, it then lay behind it, covered by the transversnlis fascia, 
which I had to divide before the^sac was able to bulge forwards 
into its usual position. It would seem, therefore, that this 
case falls under the class described by Mr, Birkett in Holmes's 
' System of Surgery,' as " B«duction en Maeae by Displace^ 
meut.'' The chief peculiarity to be noticed is that this form 
of rednctioa en tnoae has been usually noticed in femoral 
and not in inguinal hernias. 

The other two cases are examples of reduction en matte 
by laceration of the neck of the sac. They bath occurred 
during the operation for a strangulated femoral hernia. 

Cisa 2, — Mary B — , aged 63, a married woman, who had 
had four children, was admitted under my care into Lydia 
Wardj on April 7th, 1878. For two years she had noticed a 
gradually increasing swelling in the left groin, but she had 
never worn a trusa. Latterly she had suffered from a cough, 
which had caused an impulse in the upper part of her thigh. 
The day before her admission she awoke at 5 a.m. with a pain 
ia her "stomach," and soon afterwards she began to vomit. 
A little later her bowela acted, but not since. The pain 
increased, and she noticed that the swelling was harder and 
larger than uaual. A doctor was summoned, and be applied 
taxis without success. 

On admittion. — She was of a fairly healthy appearance, and 
not in much pain. There had been no vomiting for ten hours. 
That which she had brought up she described u " bilious 

. „Gooj^lf 



288 Caaea pf " Reductioa m matte.*' 

BtufiF." There was a swelling in her left groin the siie of a 
hen's egg. 

After applying taxis unsuccessfully, I operated upon her 
later in the eveniDg under chloroform. The sac was openecl. 
It contained some omentum, which was adherent to the neck 
of -the sac on the left side and behind, together with foat 
inches of intestine of a reddish-purple colour, and in parti 
rough with recent lymph. After incising the neck of the sac, 
I had considerable difficulty in returning the intestine. Each 
portion had to be pushed up with the finger, and it seemed at 
if the neck of the knuckle was adherent to the parts aronod. 
Feeling dissatisfied, I drew it all down again, and I could then 
feel something like a band round the neck of the knuckle. 
This constricting band I partly notched with the knife, aud 
partly tore it apart with my fingers. The bowel was then 
easily returned. The operation was conducted antiseptically. 

The next day she had a rapid small pulse, and was still 
vomiting. 

On the second day, as the sickness continued and she was 
in a low condition, I put her under chloroform, and made aa 
incision through the parietea a short distance above and 
parallel to Foupart's ligament. This was next joined by a 
vertical incision to the operation wound. la doing so, I bad 
to divide Pouparf s ligament and ligature the deep epigastric 
artery. After opening the peritoneum and lifting up a qaan- 
tity of omentum which lay immediately beneath it, I found 
the loop of intestine which had been strangulated dark and 
congested and in places gangrenous. Moreover, the neck of 
the loop was much constricted and acutely bent backwards 
upon itself. On drawing the loop forward some adhesions 
gave way, and some gas and liquid feeces escaped from an oval 
opening in the neck. I stitched the edges of the opening to 
the sides of the wound, but the vomiting still went ou and she 
gradually sank and died early the next day, nearly three days 
after the first operation. 

At the post-mortem examination we found general, bat not 
very severe, peritonitis. On passing my finger into the Urat 
wound, it entered a cavity above Pouparfs ligament and 
external to the peritoneum. Unfortunately, I failed to note 
the exact boundaries of the cavity, but, from what I can aow 



„Gooj^lc 



Ctuet 0/ " Reduction en masse." 389 

recollect of the case, I believe that it vas at the upper and ante- 
rior part of the pelvis, between the peritoneum and the pelvic 
fascia. Its walls were ragged and coated with blood and 
lymph. It would appear that in my first operation I had 
pushed the bowel into this space, and that when I had drawn 
it back again I had felt with my finger the opening which led 
from the artificial cavity into that of the peritoneum. Pro- 
bably I had enlarged this opening with the hernia knife and 
my fingers, but I had failed to replace the intestine through 
it into the abdomen. 

Ca«b 3. — Mary A. E — , aged 46, a married woman, was 
admitted into Charity Ward on May 22nd, 1875. For two 
years she bad had a rupture in the right groin, but had not 
worn a truss. OccaaionBlIy it went back of itself, and she 
conld always return it easily. Thirty hours before admission 
the hernia had come down. Her bowels had been moved the 
day before. She began to vomit on the morning of the day on 
which she was admitted. She was found to have a femoral 
hernia iu the right groin, rather hard, of a nearly spherical 
shape, with a diameter of about an inch, and very movable. 
Chloroform was adminiatered, and the house-surgeon operated 
under my superintendence. The aac was opened, and a 
liDackle of intestine as big as a large-sised cherry appeared. 
He next proceeded to insert his finger aod to incise the neck 
of the sac with the hernia knife. He tbeo snicl that the intes- 
tine was adherent all round the neck of the sac, and he had 
to separate it with his fioger. The protruding intestine could 
now be slowly reduced, but the houae-aurgeon said that it was 
still adherent to the outer side of the neck of the sac. This 
seemed also to me to be the case when I had carefully 
explored the parts with my finger. Bearing in mind, how- 
ever, the case which I have just related, I tried to draw the 
hernia down again into the sac, but was unable to do so. It 
was therefore with some misgiving that I desisted from the 
attempt, and applied the usual antiseptic dressing, in the hope 
that, as I could not find the knuckle of intestine, it was safe 
within the peritoneal cavity. At first her condition was no 
worse than that which often follows the administration of 
chloroform. There waa some vomiting, bat only of a little , 

TOI.IIY. 18 <^'OOglf 



290 Cases of " Reduction en maue." 

watery matter. This gradnaUy got worse, the pulse became 
rapid, and the abdomen Bvelled. Three days after the opera- 
tion I divided the autures, aod, after reopening the wound, I 
explored it with my finger. It appeared to me that the 
femoral ring was quite clear, and that my finger could be 
passed through it into the abdomen ; so I did nothiDg farther. 
She died the next day. 

I am indebted to Dr. Hilton Fagge for the following report 
of the condition of the parts at the examination which he 
made twenty hours after death. 

On opening the abdomen the peritoneum was found to be 
generally inflamed. " A knuckle of intestine was seen to be 
still incarcerated in some pouch outside the peritoneal cavity ; 
at the same time there was nothing in the sac. The latter, 
though easily tnvaginated into the peritoneal cavity, was in its 
proper place in the hernial protrusion space below Fonpart*s 
ligament. The piece of small intestine was next gently pulled 
out of the space now containing it, and it was found to be 
lying beneath the peritoneum behind the right ramus of the 
pubee, in contact with the obturator intemus muscle. So that 
there had been a ruptnre, or the parts had been incised at the 
time of the operation at the inner part of the neck, and the 
bowel in passing up had got out of the peritoneal cavity. As 
helping towards this state of things, a thick cord ran from the 
origin of the iliacs ou this side to the inner side of the neck 
of the sac, forming a somewhat projecting ridge beneath the 
peritoneum, and against which the returning bowel may very 
likely have lodged, and then turned under it down into the 
pelvis. This thick cord was the remnant of the foetal hypo- 
gastric artery on this side.^ 

I IfoU by Dr. Baton Fagge.— " With reg«rd to the cord ipoken of u tending 
to came the nibperitoDeal rednctian, a farther examioation *howed that it came 
olt from thG internal iliac on the left itde, that it ran along in, or nthcr beneath, 
the peritonemD inude ihe position of the Ysueli, and then getting to the abdo< 
inina] wall was lo«t on it, where it ceTtainlj appeared to be numiog obliqoelj 
npnardi to the median line, aa the bypogattrio artery might do. The cord con- 
tained a good-iized artery at ita origin from the intamal iliac, and tbia gave off 
brucbes to the poritoneam in the direction of the bladder, nterna, &e. (veucal 
aud nterine brancbea P). About the middle it became mnch imaller, but con- 
tianed on to the groin aa a perviona veuel, where I loat it. It tbna occupied 
much the coune of the obturator after;, except tbat it did not dip down to th« 
foramea, but was rtflected on to the abdominal wall. The oMnntot artoj and 



Cases of " Reduction en maate." 291 

" The piece of intestine, about two inches in length, was 
eighteen inches from the cscum. It was of a dark port-wine 
coloor, and the nipped portion had on the convex aspect of the 
bowel a number of small yellow points, where it was going to 
iloDgh tbroDgh, eo that in a short time a part of the canal 
would have opened to the size of a sixpence. The neck of the 
false sac did not nip the bowel at all tightly ; I should have 
thought with a grip insufficient to canse either obstruction or 
(trangulatioD. I am also inclined to think that had there 
been any peristaltic action at all on the part of the intestine, 
it would hare worked itself out of its incarcerated state. The 
bowel below the stricture to the csecnm waa closely con* 
tractcd." 

Although I have heard of other cases similar to those which 
I have related, I am not aware that any writer baa pointed 
□ut the risk of retarning the intestine into an extra-peritoneal 
pouch after opening the sac in the operation for femoral 
hernia. It seemed to me, therefore, very important to place 
these cases on record, so that others may be aware of the 
possibility of such an occurrence. At the same time I would 
add a few words upon the conditions which predispose to it, 
the mode of its production, the way in which it may he 
avoided, aud the treatment when it does occur. And, firstly, 
I consider that in these cases there is probably an unusual 
looseness iu the connections of the peritoneum lining tbe 
femoral ring and the adjacent part of tbe abdominal cavity to 
tbe fibrous aud other structures with which they are in con- 
tact. Perhaps, also, the neck of the sac lies more deeply 
than normal above the level of Qimbernat's ligament and the 
femoral ring. For example, in Case 3 it seems probable that 
the inner boundary of the neck of tbe sac was formed by the 
ridge of peritoneum which covered the obliierated hypogastric 
artery on its way to the anterior wall of tbe abdomen. If so, 
it must have been considerably deeper than the level of 

the dMp epigoitric came off bj > common trank from the Mtemnl iliac, the 
Iitt«t bring quite Dormnl, the fornieT nuniDg over the hernial neck and down on 
it* inner uds to tbe obturator foramen, lo that it occupied the sunricatly 
dingetou potltion delcrib«d in anatomical worki, bat }et had eirnped being 
wmmdfd." 



.y Google 



293 Ca$e» j/ " Redaciim en matse.'^ 

Gimbemat's tigament, the usual position of the neck of a 
femoral hernia. In the second place, the mode of productiou 
Toold appear to be as follows : — The operator divides the edge 
of Giimbernat's ligament on a plane superficial to the true 
neck of the sac, and having thus slightly notched the peri- 
neum at the femoral ring, he further widens the opening by 
thrusting in his finger. At the same time the narrow neck 
of the sac lying above the level of the femoral ring, and 
having escaped his knife, is pushed upwards, together with the 
adjacent peritoneum, which is readily separated from the 
abdominal wall. A csvity is thus formed, into which the 
knocltle of intestine is returned, while its neck remains in a 
state of strangulation as before. As the opening formed by 
the knife is on the inner side of the femoral ring, the false sac 
is naturally formed upon that side, and the fact that it lies 
within the cavity of the pelvis prevents any bulging which 
would betray its formation. 

In order to avoid such an untoward event, I would suggest 
that the large flat director should be used in all cases in 
which the finger cannot be easily introduced into the femoral 
ring. We may be quite sure that this will pass into the 
interior of the peritoneal cavity, and the hernia knife when 
passed along its groove will be certain to divide the peritoneal 
neck of the sac as well as the more fibrous external constric- 
tion at the edge of the femoral ring. If there should now be 
any difficulty in returning the protruded intestine I should 
advise the careful division of all the structures which lie in 
front of the sac as far upwards as Poupart's ligament. This 
can do no harm, for it does not entail the interference with 
any important vessel or ligament, while it lays bare all that 
part of the hernia which lies outside the femoral ring, 
diminishes the depth which has to be traversed by the finger 
in order to reach the neck of the eac, and, lastly, by cutting 
through the attachment of the upper extremity of the falci- 
form ligament to the under surface of Gimbemat's ligament, 
it may remove an obstacle to the return of the hernia. There 
is much reason for apprehension when a recently-descended 
femoral hernia does not slip up readily after the neck of the 
sac has been fully dilated hy the incision of the hernia knife 
and the subsequent intn>duction of the finger. If the iQtes* 

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Catei of " Reduction en matte" 203 

tine has, so to speak, to be packed up piece after piece hy the 
fiDger, and if the operator has the sensation of dealing with a 
knuckle of intestine fixed by firm adhesions at the neck, 
Blthongh there ia no appearance of old inflammation on the 
put which he can see ; if, again, the cavity into which it can 
be poshed seems to be limited by adhesions, I think it is very 
probable that be is making a mistake similar to that which 
«u fatal to the two patients whose histories I have related. 
Under these drcumstances his first eudeaTour should be to 
draw the knuckle down again into the proper hernial sac. If 
he should be unable to do this, as happened to myself in 
Case 8, I consider that he had better make an incision above 
aud parallel to Foupart's ligament^ which will enable him to 
explore the inguinal portion of the abdominal cavity. Should 
it appear to be necessary, he might still further extend the 
opening by prolonging upwards the vertical incision to meet 
it, thns dividing Foupart's ligament and probably also the 
deep epigastric artery, I am disposed to think, howerer, 
that in most cases a free incision throagh the parietes above 
Foupart's ligament Toald be sntScient. The operator will 
then be able to examine the femoral ring from above, and it 
wilt be easy to withdraw the kuiickle of the intestine from the 
eitn-peritoneal pouch into which it has been thrust. Unless 
the mistake is at once rectified there is very little chance of 
saving the patient's life. The symptoms of strangulation 
continue, but, as would appear from my two cases, they are 
not so urgent aa to make it obvious that nnother operation is 
immediately required. Probably the return of the hernia to 
the false sac diminished to some degree the constriction upon 
its neck. At any rate there was bat little pain, and the 
Tomiting was so slight as to render it doubtful whether it was 
not due to the administration of the chloroform. Wheo it 
bat become quite evident that an exploratory operation is 
imperatively called for, I fear that in most cases we shall find 
that some portion of the constricted gut has become gao- 
grenons, and that all our eS'orts to save the patient's life by 
forming an artificial anna or otherwise will be unsuccessful. 



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,Google 



OHEONIO BRIGHT'S DISEASE WITHOUT 
ALBUMINURIA. 



Bt F. a. MAHOMED, M.D. 



That the urine in chronic Bright's disease is ocoasionftlly, 
or even not infrequently, free from albumen is by no means a 
novel observation. The object of this paper is to prove some- 
thing more than that ; it is to prove that in the earlier stages 
and in most cases even to their final stage, the nrine of what 
is generally known as chronic Sright's disease with red 
grannlar kidney, is most commonly perfectly normal. More 
than this, its otgect is to prove, either that chronic Bright's 
disease is not a renal disease, although it frequently gives rise 
to a renal affection, or else that another disease must be 
recognised, which constantly precedes and prepares the way for 
Bright's disease, which may be called arterio-capillary fibrosis, 
or any other name that may be preferred to it. For my own part 
it seems preferable to retain the name o£ " Bright'* disease " for 
the general condition, nearly all the pathological results ot* 
which Bright so accurately described, and to say that though 
the associated changes of granular kidney, hypertrophied heart, 
and atheromatous arteries were all described by him, yet his 
interpretation of their relations and causation was not 4a d) 

. „ Google 



29G Chronic Bright's Diieate without Albuminuria. 

cases correct ; that it is probabl; true in man; cases of tbe 
acute disease, but tltat we have learnt in time bo to extend 
our views that we dow include a much wider field when we 
speak of the pathology of chronic Bright's disease than that 
which Bright descnbed, though possibly not a wider one thin 
he suspected when he insisted on the insidious character of the 
malady which bears his name. 

It is not proposed to enter here into a miuute inqniij and 
adjudication upon the merits of the varied descriptions of the 
histology of Bngfat's disease that have emanated during past 
years from Germany or other countries; that duty has lately 
been performed for us by a most judicial mind in Dr, 
Soathey's recent Lumleian Lectures at the College of Physiciani. 
Those observations, as they are thus ably presented to us in 
review, appear somewhat too minute; they are descriptions in 
many instances of small groups of individual cases rather than of 
a whole disease, and founded too much on pathological and too 
little on clinical observation ; their detail is admirable, but 
tbeir generalisations seem wanting. AU the various writers 
seem to ol^ect most strongly to look for an eiplanation of 
what they see beyond the coniinea of the kidney, and in this 
Dr. Southey would appear to follow them. 

Where there is so much confusion sod disagreement it is 
difficult to say where we shall find a common standpoint and 
sure footing. I shall therefore speak of Brighfs disease as I 
have known it by the traditions and doctrines of its birth* 
place, and as I have learnt it by my own observation. The 
traditional teaching concerning Bright's disease at Guy's Hos- 
pital cannot be better illustrated than by a quotation from Dr. 
Southey's lectures : — " la 1853, Dr. Wilks published an article, 
entitled Cases of Bright's disease, in the ' Guy's Hosptal 
B«ports,' 2nd series, vol. viii. He began by expressing bii 
preference for the name of Brighfs disease over that of 
Albuminuria; since renal disease, he found, might exist and 
no albumen escape in the urine, and albuminuria might 
occur temporarily without depending upon any such lesions si 
Bright had described in the kidney. Brigbt's disease, be 
acknowledged, was still very imperfectly understood, patho- 
logically or clinically ; but certain well observed structural 
changes in the kiduey, accompanied by a r^ular train of 



z.c.y Google 



Chrome Brigh^t Dueate without Atbumitmria. 2Q7 

symptoms and secondiury pathological phenomena, might Le 
TOachsafed to iiidic»te it." — "At p. 238 he writes : ' Id chronic 
gruiular kidney the orine is often in good quantity, contain- 
ing no deposits, snd may or may not be albuminous.' Dr. 
Vfiikt pronounces himself as a very poaitive dualist, and 
diacriminates two principal forms of Bright's diseaBe — the 
large white and the small granular— and then describes the rarer 
□r lesBervaheties, the mixed forms, and secondary forms, of later 
writers." — " He is the first author I have read who points out 
plainly that the large white kidney may have two modes of com- 
mencement: either by acute general dropsy,or quite insidiously. 
He is the first to speak of granular kidneys as indicating 
senility ; to notice how (vide p. 256} ' the older the patient is, 
tbe more liable is he to granidar degeneration of the kidney ;' 
and he remarks upon the thick tortuous radial arteiy, the 
general ansmia, the characteristic pale urine, and the desire to 
micturate frequently, as well as the tendency to death by 
apoplexy or nrtemia in this chronic malady. He compares 
the changes in the large white kidney to bronchitis in the 
Inogs, which may be recovered from entirely, or may pass on, 
by extension of the inflammatory processes through the 
parenchymatous tissue of the organ, to degenerations analogous 
to those which take place in broncho-pneumonia. His de- 
tcriptioD of Bright's disease leaves nothing to correct andlittle 
to add ; but he is not much captivated (vide p, 274) by 
Johnson's theory of tbe mode in which the albumen escapes 
from the blood, attributing the albuminuria, straightforwardly, 
to obstruction of the circulation through the tufts and capil- 
laries, and not to its transudation through the tubes, because 
of their being denuded of cells." 

Later on, a^r reviewing all the contributions to the 
pathology of the disease from that time (1K52} to the 
present, Dr. Soutbey anms np : — " Finally we mutt admit 
thai the indefinite niimder of intermediate forma [atked for 
by Dr. Wilks in former times) between the two typical varie- 
iiei are now admitted to exist in great number, and become 
m even stronger argument in favour of the doctrine of 
one Brighfg diaeate." la this remark I am most fully in 
sccord with Dr. Southey. With regard to the next great 
aiivancc in tbe pathology of Bright's disease, which Guy's 



398 Chronie Bright'* Disease without Albuminuria. 

teaching has again offered to the medical world, let me once 
more quote Dr. Southey'a impartial opinion upon a subject upon 
which I shall have to speak later. " Arterio-capillary fibrosis 
appears to us a change wholly apart from senile degeoeration, 
and from atheroma ; it is a moat real change, separate from 
that mnscnlar hypertrophy which usually accompanies it and 
involnDg the entire thickness of the capiltaries and the walls 
of the small arterioles. Essentially, it is a chronic irritative 
or inflammatory change ; it is the oaose, perhaps, wholly of 
one form of renal degeneration ; hat it occurs in more or less 
degree in all, It is a change far more widely spread through- 
out the body than was at first suspected ; it has a most 
important bearing upon those so-called accidents, secondary 
serous inflammations, liver cirrhosis, lung ledema, pneumonia, 
meningitis, cerebral and spinal complications, which were 
thought formerly to be due to the irritament of an impure 
blood. Its recognition is a great step in advance and one 
which will, in due time, be appreciated, but it is still probably 
a part only of the whole truth, which subtends the wide subject 
of chronic inflammation. But we still reserve our opinion that 
Bright's disease is a real entity, and that, while granular 
atrophy may be a consequence of this in its most gradual and 
complete degree, it is the renal disease which gives the 
characteristic features to the widespread general phenomena." 

To proceed now more directly to the argument of my thesis, 
let ns take up the subject where Dr. Wilks left it, and say 
that two forms of kidney are generally recognised under the 
term chronic Bright's disease, namely, that in which the 
kidney is more or less " large and white," this form being 
characterised daring life by the presence of much albumen and 
much dropsy, and that in which the kidney is more or less con- 
tracted and red, characterised by the presence of little if 
any albnmes or dropsy. With the former of these groups we 
shall have nothing to do in the present paper ; it is unfortunate 
that they have ever been classified as chronic ; they are strictly 
subacute; if they live, they recover, or become chronic, in 
either case changing their structure, so as to be no longer 
recognisable ; if they die, they do so comparatively soon, too 
soon to be tmly chronic, too late to be acute. 

Now, in the various forms of Bright's disease rpost observerq 

Cioogle 



Chrome Brighfa Diteate withotU JJbimintiria. S99 

are now agreed that the changes in the kidnej may be 
ananged under three heada ; — 1. Epithelial changes. 2. 
Interstitial cell growth and fibro-hyaline change. 8. Vaaenlar 
and penvascolar thickenings. Of these the epithelial are 
associated more commonly with acate or subaeate disease, 
and therefore with mach albnmen and dropsy; the inter- 
stitial with chronic disease, and therefore with little albn- 
men and dropsy : but on the one hand the epithelial changes 
may frequently be net with Ih chronic diseasej thongh 
alone it is more characteristic of acnte ; while on the other 
the interstitial changes are very commonly met with is acnte 
disease, thongh alone they are more characteristic of chronic. 
The vascniar and perivascnlar changes may be either chronic 
or acnte, the acute vascular and perivascular changes comprising 
those described first by Klebs, afterwards by Axel Key, and 
others, and known as "glomemlar nephritis;" the chronic 
vascular changes are the thickenings of Malpighian capsules, 
of arterial coats, and the fibro-hyaline exudations of Gull and 
Sotton, confirmed by Ewald and others. It is with the clinical 
history of these latter changes that it is proposed to deal at 
present. The fact that these anatomical changes should be 
found in the vascular structures itself suggests that its cause 
should be sought in the condition of the vascular system 
daring life. Now, it is well known that the arterial pressure 
is greatly increased in all forms of Bright* s disease, and we 
have therefore a ready explanation of the changes found after 
death. Increased work in resisting Dver-distension has pro- 
duced hypertrophy of the muscular cost, while distension and 
strain have produced thickening of the fibrous and elastic coats ; 
umilar changes are seen in the intestine and other muscular and 
fibrons tubes when they have increased work thrown npon them. 
Bat if due to this cause not only should the arteries of the kid- 
neys and the Malpighian capsules become thus thickened, but a 
similarthickening should extend to all the vessels of the body and 
to the adjacent tissues. This has been shown by the researches 
of 8ir William Gull and Dr. Sutton to be the case ; they have 
especially demonstrated it in the brain and spinal cord,' and 
have shown the extension of the fibro-hyaline thickening of 
the adventitia into the snrnmndiog delicate nervous stroctarea. 

' <Tniu.Piith. 800,' VOL asriii, 1677. C (XIqIc 



800 Chronic Bright't Diteete without AUrammuria. 

Dr. Klein' has ehown a very Bimilar thickeuiug occurriog 
as an acute condition in Bcarlatinaj in which disease I have 
elsewhere demonstrated that the arterial pressure is com- 
monly uadul; high.^ Further evidence of the thickening of 
vessels prodaced by distension is seen in the well-known local 
thickening of vessels in an inflamed area ; this also is well 
shown by Klein in the intestines and spleen of enteric fever. 
We should, therefore, be prepared to admit that in Bright's 
disease the vascular changes are sufficiently accounted for by 
the increased arterial pressure. The more sudden and intense 
the increase of pressure the more severe will these changes be, 
and the larger will be the amount of cellular exudation in the 
region of the vessels and in the capsules of the tufts.^ 

But if high pressure produces these changes in kidney dis- 
ease there is no reason why, if high pressure occur without 
kidney disease, it should not produce similar changes. Now, I 
have elsewhere shown* that high arterial pressure is not 
a coTueguence, but an antecedent of kidney disease. In 
the acute condition, as seen in scarlatina, the high pressure 
can be recognised in the pulse before (and experience has 
since shown long before) the kidney gives any sign of 
failure or albumen appears in the urine, and that treatment 
of this high pressure usually averts or cures the kidney 
trouble ; while as a chronic state I have also shown' that 
high arterial pressure occurs in some persons from youth 
upwards, apparently marking them out for future Bright's 
disease, and that it is common in lead poisoning, alcoholism, 
pregnancy, dyspepsia, and other conditions predisposing to 
Bright's disease ; that it occurs in them long before there is 
any sign of renal failure or organic vascular changes, which 
probably require, in most cases, years to develop. It there- 
fore follows that these chronic conditions of high arterial 
pressure will produce in the kidney and elsewhere the vascular 

* "Scsrbtinal ConvaleMenoe," ' Practitionar,' 1BT5. 

* Tbia ii the reuoo for the extreme channel in ■o-ealled glomernlu' aephrlti*, 
bnt thoDgfa ttiia ia common in tcarlatina. it ii not conQned to thLi diMaie. I hare 
■Mil it in noa-scarlatinal ouei. It onlj reqaira ■ lofficieDt intensitj and 
■addenncsi of oniet ia aprevioailyhcalthTkidne;; there is nothing apeoiflc In it, 

* " Etiology of Bright'! Diieaae," > Trana. Med. and Chir. Soc/ 187*- 
e "Clinical Aipecti of Bright't INhu<s" ' Oojr'* Hoap. R^ort^' 1879, 

. „Gooj^lf 



CArofltc Brigkt'a Diteate urithoul Alhmiinvria. 30l 

and periviucular changea of Brighfs disease already rererrecl 
to. 

Again, since it has been demonstrated that this vascolar cod- 
dition frequently piecedes and ushers in both acute and chronic 
renal diteate, and that it produces the vascular changes charac- 
teristic of Bright'a disease, it follows that this general and 
is elusive term, B right's disease, indicates not so much a 
primary renal disease bs a general or blood disease in which 
the kidney is especially liable to be attacked, though it is 
well known that it sufTers not alone, but in company with 
several other organs, notably the lungs, which are almost 
constantly affected by bronchitis, the stomach and intestines, 
which suffer from catarrh, and the akin, which haa catarrh of 
of its sweat ducts. 

Dr. Saundby, of Birmingham, in a most suggestive article,^ 
entitled the " Functional Stage of Granular Kidney," has 
itrongly supported the view I put forward in the ' Ouy's 
Reports,' thiit the condition of permanent high arterial 
pressure is an early stage of granular kidney. 

From these considerations it follows that we have to deal 
nitb three stages of chronic Bright's disease : first, the fimc- 
tional atage, which is limited to the condition of high arterial 
pressure without organic changes in either the vascular 
system or the kidneys; second, the chronic Bright't diteate 
without nephritit, the stage of organic changes in the vascular 
system and in the kidney (for which, if thought desirable, the 
term " arterio-capillary fibrosis " raight be employed) ; thirds 
chronic Bright's disease with ne|)hritis, the natural, but by no 
means the invariable, termination of the disease ; epithelial 
changes have now taken place in the kidneys, or the cirrhotic 
changes are extreme, and the symptoms of renal disease have 
become prominent. 

Of these stages the third ia well known, it is the form of 
this disease commonly diagnosed ; the second is the one to 
which this thesis is devoted. The first appears to have every 
probability in its favour, bat it requires years to prove it, as 
the cases must be watched from youth into old age. 

The kidney of the second stage, to the naked eye, is purely 
red, more or less granular, the capsules will be somewhat and 
> ' Binnlngliun MetUcsl Beriew.' 

D,9-zec.yGOOglf 



802 Chronic Brighfa Disease without AJbumimtria. 

perhapa extremely adherent, the cortex atrophied little or 
much, the cat ed^ crenatedj the arteries distinctly thickened, 
gaping, and promineut, the heart more or less hypertrophied ; 
in some cases the kidney may look perfectly healthy, perhaps 
the arteries alone may look a little thick. The microscope in 
these cases will show thickened membrana propria of the 
tnbulea, thickened capsules of the Malpighian tafts, more or 
leas iutertabular fibro-hyaline thickening, the arteries thickened 
both by hypertrophy of the muscular and fibro-hyaline thicken* 
ing of the intima and perhaps of the adrentitia ; the epithelium 
will be normal or only a little granular, not increased in 
quantity. These kidneys differ from those of the third stage, 
inasmuch as the latter to the naked eye show grey or yellowish 
granulations in the cortex, these appearances being dae to 
excessive proliferation of the epithelium of the tubes; the 
condition is so distinct that it is easy to recognise, by the 
presence of grey or yellowish mottling, the existence of any 
epithelial changes in the kidneys. These latter kidneys 
almost invariably give rise to albuminuria, and not uofre- 
quently to dropsy. These epithelial changes may probably 
come and go at any time in a kidney of the second stage, 
giving rise to the numeroas exacerbations and intercnrrent 
acate attacks to which these cases are so liable. 

It ie kidneys in the second stage, or red granular kidneys, 
which in my opinion give riae to no albumen in the urine nor 
any dropsy; they can be diagnosed by the cardio-?ascular 
signs alone. In a series of papers, entitled "The Essential 
Symptoms of Chronic Bright's Disease,"' I first put forward 
this view, and if I appeared to do so with nnpardonable 
dogmatism, it was because of the large number of cases which 
I had seen, though I failed then to record any. My chief 
argument at that time waa founded on a table of 100 caaes of 
granular kidneys which I extracted without selection from 
the pathological reports of Guy's; this table showed that 26 
only, out of thia 100, presented, during life, symptoms which 
would have been recognised aa tboee of Brigbt's disetiee ; the 
others came under treatment for symptoms of cerebral hnmor- 
rbage, heart disease, lung disease, and sundry medical and 
surgical diseases; it was, moreover, found that these two 
' 'Lanoa^* vd. i, 1879> 

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Chrome Srighft Disease wilhout Albuminuria, 803 

claasea of 26 cases with kidney aymptonis and 74 without 
were also divided pathologicall; into exactly the same groups ; 
the first 26 were cases of muted or mott1»l ^anular kidney, 
the other 76 were red granular kidneys. 

Dr. Saundbyj in a short note on the " Occurrence of 
Dropsy in Granular Kidney,"' introduces a table showing the 
diagnosis — which was sent &om the wards to the post-mortem 
room at the Birmingham General Hospital— in 98 caseSi in all 
of which the kidneys were granular ; out of these 98, only 22 
were sent down with the diagnosis of Bright's disease ; of the 
rest, 16 were diagnosed as "morbas cordis," 11 as apoplexy, 8 
as long disease, the rest as varioas medical and surgical 
affections, inclnding 4 of erysipelas and 4 of gangrene. We 
ihall be nearly correct, then, if we say that only about 26 per 
cent, of the cases of grannlar kidney give rise to the ordinary 
lymptoms of Bright's disease, namely, albuminuria and 
dropsy, and we may add that these have mixed or mottled, not 
aimple red granular kidneys. 

The two plates which accompany this paper represent the 
condition of the kidneys in two cases in which the changes 
indicative of the red granular kidney, without inflammatDry 
lesions (that is, with little, if any, small-celled growth), were 
present. For these excellent drawings, made to acale, I am 
indebted to my friend Mr. George Turner. In Plate I the 
changes are exhibited in a very well-marked degree. In Plate II 
the changes are slight; the kidney might be described as 
"coarse," indeed the existence of disease in this specimen has 
been questioned by some obaerrers. Dr. Klein, however, has 
kindly examined the original slides, and states that he finds 
the following changes in both specimens, and that they are 
present in Plate I to a very advanced degree. " The membrana 
propria of the tabules is thickened, both in the coitex and 
in the medolla; it is accompanied by thickening of the 
hyaline capsule of the Malpighian corpuscles, involving the 
vessels of the glomerulus. There is a hyaline thickening of 
the intima of the arteries and thickening of the muscular 
coat of the smaller arterioles." Dr. Klein remarked that 
the changes were similar to those he has described as occumng 
in scarlatina, and in the intestines and spleen in enteric fever, 
1 < BinniDgtuun Ued. Beview,' April. 1881, 

D,9-zec.yGOOglf 



304 Chronic BHght's Diseate without Aibutninvria. 

to wliich I have nlready allnded. Owing to the tbickeningol 
tlie membrana propria of the tubules the processes of thst 
membrane which pass inwards between the cells, separatiDg 
them from each other and retaioiDg them in position, can be 
seen in Plate II more distiuctly than in any specimen I ban 
ever examined. 

We may pass now to the consideration of the series of casei 
upon which I rely to prove my proposition that this stage 
of chronic Bright's disease gives rise to no symptoms of 
renal failure. These cases have been collected almost entirely 
from among the medical patients in Quy's Hospital during the 
brief period of t\TO years 1879-1880, that is to say, out of 
a total number of about 4000 cases. They only include 
those in which there was what I considered positive evidence 
of organic disease. I have excluded many the apex of 
whose heart could not be detected, although they might have 
a very typical pulse ; some too have been rejected whose urine 
has not been watched with sufficient frequency or whose reports 
are too imperfect to place any reliance upon them. None, 
therefore, have beeu included who presented the symptoms 
of high arterial pressure alone, without any evidence of hyper- 
trophy of the lieart or of renal disease. 

The cases number sixty-oue in all ; of these twenty-one 
proved fatal while under observation nod the results of the 
post-mortem examinations are appended. These examinationa, 
be it observed, are not made by advocates o£ any particolar 
theory, they are not likely therefore to be strained to suit 
the views here put forward. It would be difficult to find two 
more competent and impartial observers than Dr. Hilton 
Fiigge and Dr. Goodbart. 

In addition to their more prominent symptoms for which 
they sought relief, nearly sU these cases presented the follow- 
ing charftcteristica which led to. their diagnosis: — They all 
had the signs of high arterial pressure ; they all had very 
considerable hypertrophy of the heart, those cases only being 
accepted in which the apex bent was in the nipple line 
or external to it ; in many the arteries were tangibly thickened ; 
in all cases the urine was free from albumen while they were 
under observation. In most of the cases it vraa altogether free; 
in eleven casea albumen was present on one or two rare occuions 

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Chronic BrighVs Diaeate without Jlbuminuria. 305 

daring n long period of careful obserrations, this happened imme- 
diate!; after admiBBion to hospital and during the time they vere 
■ererely ill ; in three cases, though absent during long periods 
of obseiration, it occurred just previous to death ; in three 
other cases of typical chronic Bright's disease, the patients 
were admitted with albuminuria, which disappeared under 
treatmeut aad they left vithout it. Three cases had urine 
very variable in its characters, sometimes albumiuous, sometimes 
not. In the remaining forty-one cases albumen was never 
discovered in the urine. The exceptions to well-marked 
hypertrophy of the heart were seven in number — three of the 
fatal cases ; in one, a case of phthisis, in which there was great 
wasting, the heart only weighed II oz., but the kidneys were 
very granular and the arteries thick ; in another, a ease of 
severe arterial disease, with much disease about the commence- 
ment of the aorta, the heart weighed only 12^ oz., the body 
was spare and the muscles small ; in another case, of a female 
with much wasting, the heart weighed only 13 oz., the kidneys 
being, however, markedly granular and the vessels thick. In 
all the other cases the hearts varied in weight from 15 oz. 
to SO oz. Of the cases which were not fatal, in four the 
hypertrophy was not proven by displacement of the apex beat ; 
in one of tiiese there was renal dropsy and occasional albumi- 
nuria, in another bronchitis and emphysema with severe 
epistazis, the arterial pressure being extremely high and the 
arteries tortuous, hard and thick ; the other two were ordinary 
and generally accepted cases of Brighfs disease in which the 
albumen disappeared while under treatment. Of the twenty- 
one fatal cases all had thickening of the arteries visible to the 
naked eye ; all had well-marked hypertrophy of the heart 
with the exception of the three cases mentioned above ; in 
ten cases the kidneys were of the ordinary red wasted and 
granular variety. Two were large and granular, but proved 
on examination to have merely the vascular changes to be 
mentioned hereafter, with very little if any small-celled 
(inflammatory) growth. In three the kidneys were of the 
mixed or yellow granular variety. In five cases the kidneys 
appeared perfectly healthy to the naked eye, of good size, with 
smooth surfaces and thin capsules ; in all of these, however, 
it is noted by Dr. Fagge and Dr. Goodbart (who made the 



806 Chrome Briffht's Diteate without Albuminuria. 

post mortemB] that the small art«ries vere thickened and 
prominent ; in three of these the microscope stowed thickening 
of vesselB, Malpighian capsules and stroma, the other two weie 
onfortonatelf not examined microscopically. 

To the reports of cases tables of daily obserrationa on the 
urine are appended ; in these tables are recorded daily obser- 
Tations on the quantity, specific gravity, solids, and albumen 
present in the urine, and in some also is added a record of the 
number of actions of the bowels in the same period. The 
columns of figures beaded "solids" are obtained by multiplying 
tbe last two figures of the specific gravity by the number of 
ouQces of urine passed; the product is a purely empirical 
number, without any relation to grains or grammes, but it 
affords a convenient standard for comparison, taking tbe normal 
quantity of urine to be 50 oz., and the normal specific gravity 
to be 1020, the normal solids will be 50x30 = 1000, a 
number which commends itself as a convenient standard. 
Unfortunately these tables cannot be relied upon as strictly 
accurate. The quantityof urine has been measured by the nurses 
and the tables constructed by the clinical clerks. It is always 
difficult to induce the patient to carefully save all the urine 
passed ; this difficulty is more especially felt in the female 
wards. In many cases these tables can only therefore be taken 
as giving minimutn quantities, and a liberal addition may often 
be made to them. Each table must be jodged upon its merits 
in this respect, and it will not be found difficult to deude when 
they are inaccurate. This is especially evident when, without 
any apparent reasonj very great variations occur from day to 
day in the quantity passed. The physicians to the hospital 
have been, as they always are, most liberal in according me 
free use of their cases ; to them I tender my most sincere 
thanks. It is right that I should say they are in no way 
responsible for the diagnoses made in these cases, with many of 
which, possibly, they would not be disposed to agree; I have 
tried as far as possible merely to state facte and to leave others 
to draw their deductions from them. The main facts stated 
in oU but two or three of these reports were verified by myielf, 
all but these few exceptions having come under my own 
observation. Nearly all the observations on the poke are 
from my own dictation. 

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Ohnmie Briffkt'$ Diteate wnlhout Albumnuria. 



I. Catet of heart failure. 

The first groQp of cases consist of ten cases of failure of the 
heart dne to high arterial pressure, of theee no less than eight 
were fata], and the diagnosis which was made during life was 
confirmed by the post-mortem examioatioo. Such cases as 
these were described in my paper in the 'Gay's Reports' for 
1879, and tbey need not now be discussed at length. Unfor^ 
tunately, in these cases, as tbey were nearly all extremely ill, it 
was difficult or impossible to obtain a complete account of the 
urine. lu the Case 1, however, a rery raluable record was 
obtuned, by which it is evident that the urine when he was first 
admitted was normal both ia quantity and specific gravity, but 
that as liis cardiac failure increased the nrine, as it usually 
does under the circumstances of venous congestion, became 
scanty, but of very high specific gravity. It once contained 
a trace of albumen shortly after admission, and not again till 
the day before death ; this is the more remarkable as severe 
venous congestion existed during the whole period. An 
accurate record of the urine has been kept in Cases 7 and 8, 
In Case 7 there was a trace of albumen on the day after 
admission, but it was never found again during her stay in 
the hospital of about three months. Her urine was, however, 
of rather low specific gravity, varying from 1010 — 1015. In 
Case 8 the urine was carefully recorded throughout the whole 
of her stay (nearly a month) and was perfectly normal in all 
respects. 

In all the remaining cases albumen was entirely absent 
whenever the urine was examined, except in Case 9 in which 
it wsB usually present, but occasionally absent ; this case is 
incladed only as showing that even with the mixed form of 
granular kidney albumen -may not be present in the urine on 
&U occasions. 

In all of these cases there was well-marked (in some 
extreme) hypertrophy and dilatation of the heart, diagnosed 
during life by displacement of the apex beat, and in the eight 
fatal cases confirmed by post-mortem examination. In none 
of the cases was there any primary valvular lesion, although 



308 Chronic Brigh^M Dtteaie vnthout Alhttmitaeria, 

the valves were thickened in several by the chronic hyper- 
trophic endocarditis, which constantly affects valves subject to 
high pressure. In five of the cases there was severe aortitis 
deformans, giving rise to the bruit of aortic regorgitation in two 
(Cases 1 and 2), in. both of which the valves were more or less 
shrunken and inefficient. These five cases (1, 3, S, 4, 5] 
closely resemble Cases 9 and 10 of my previous paper. These 
cases of aortic disease, due to high pressure, can always be 
easily distinguished from those of true valvular disease by 
taking the pulse as a guide, as I have previously pointed oat. 
The pulse of true valvular disease ia essentially a pulse with 
starved, empty arteries; while in these cases, although the 
pulse may still bavo the character of " splash " more or iess 
developed, it will be persistent, and the artery tortuous and 
usually thickened. 

In Cases 6, 7, 8, 9, and 10, the mitral valve had failed 
owing to dilatation of the heart. In neither case was the 
valve diseased. In Case 7 the mitral regurgitant bruit was 
ouly of temporary duration. In Case 9, no bruit was heard, 
though regurgitation probably occurred; the cavities of the 
heart contained old ante-mortem thrombi. Id Case 10, the 
ordinary bruit of mitral regurgitation was present, but her 
symptoms indicated great dilatation of the right aide ; her 
disease was complicated by perihepatitis and frequently recurring 
ascites; she closely resembled Cases II and 12 of my previous 
paper. In Cases 6 and 8 a presystolic bruit was heard ; this 
was very well marked in Case 6, the bruit was typically pre> 
syslolic. The post-mortem showed that the valve would admit 
four fingers and that it had allowed regurgitatiou to tike 
place. In Case 8 the bruit was not constant, it disappeared 
as she improved. These cases resemble Case 6 in my previous 
paper, iu which a presystolic bruit occurred with a normal 
mitral valve. I gave my reasons in that paper for accepting 
Dr. Turner's observations, that a presystolic murmur frequently 
occurs in dilated hearts with wide mitral orifices ; that it is in 
fact due to a commencing regui^tation which is arrested ; that 
the first sound as heard in these cases does not indicate the 
commencement of systole, bnt only the moment of closure of 
the mitral valves. Their closure may be delayed cither by 
their rigidity, or by the dilated orifice, or by their shortened 

. , Google 



Ckfordc Briffhft Diteate without Albuminuria. SO'J 

chordie, until au appreciable time after systole has commeoced ; 
daring this interval re^rgitation takes places, it is cat short 
by their closare, and the brnit is arrested by the first sound, 
giTiag it the character of the presystolic bruit. 

These cases of mitral Ffulure can, like the others, be dis- 
tinguished from tme valmlar disease by the pulse, which is 
persisteDt, vbile the artery may be more or leas thickened. 
The persistent pulse appears to be very rare in ordinary 
mitral valvular disease, where again the arteries are rather 
starred than over-filled. These cases lose the characteristic 
<Iiudity of length, owing to the usually prolonged systole being 
cat short by the regurgitation through the mitral valve, giving 
the blood two modes of exit from the ventricle. 

In all of these eight fatal cases the arteries were thickened 
and the kidneys more or less granular. Each of the cases is 
worthy of more careful study from its own distinctive 
characters, but time will not allow me to refer to these, which 
would, moreover, distract from the main object of this paper. 



II. Caiea of lung faUvre, 

This group includes eleven cases, of which six terminated 
fatally, and in these the results of the necropsies are given. 
In all the remaining cases unmistakable hypertrophy of the 
heart, very remarkable increase of pressure, and in most an 
easily recognised thickening of the arteries, proved the exist- 
ence of chronic Bright's disease. They are all cases which 
presented clinically the symptoms of various forms of luug 
disease, but in all of which, with the exception of one (Case 14, 
which I did not see), an examination of the heart and pulse 
enabled me to recognise the underlying Bright's disease. 
This gronp is scarcely sufficiently well represented to convey 
an idea of its importance. The association of bronchitis with 
various general, or so-called blood conditions, is too well 
recognised to need demonstration here ; its coincidence with 
the ordinary Dephritie of Bright's disease has been frequently 
pointed out. Dr. Wilks often remarks that you never see 
Bright's disease without it. The gouty diathesis is held to 
account for many cases of chronic bronchitis, and I 8m_con' 

. „Gooj^lc 



310 Chronic Bright** Diieate without M&uminuria, 

TiDced tbat anrecf^ised chronic Brighfs diseue, -without 
nephritis, aecoanta for man^ more. In a very large propor- 
tion of the caaea of bronchitis admitted into Guy's I hare 
noted the association of high arterial preasore with it ; bat 
most of them are ontyailable for the present purpose for two 
reasons : among those that were discharged relieved it wu 
dlfficolt to demonstrate the organic changes of Bright's 
disease, because the emphysema of the lungs disguised the 
hTpertrophy of the heart ; of those that died, nearly all came 
in aererely ill, and in this stage they mostly have a trace of 
albumen in the nrine, whereas, if they had been seen before 
the serere symptoms arose, the urine wonld probably hare 
been found normal. I have notes of three very strikiug 
fatal cases of this description, in which the symptoms were so 
entirely pulmonary that they were regarded clinically, two as 
cases of severe bronchitis, the other as one of pleurisy, but in 
each the exceedingly high arterial pressure led roe to recognise 
Bright's disease. All of these three cases had a faint trace of 
albamen in their uriae, not more than tbeir venous congestion 
might well have accounted for had their kidneys been healthy, 
but still sufficient to exclude them from this paper ou Brighf s 
disease without albumiuuria. Case II is a very typical example 
of this class : the patient was a chronic bronchitic, and liable to 
attacks of very great severity, when he became intensely cyan- 
otic. He bad previously been in the hospital, and was regarded 
as n case of bronchitis and emphysema ; his urine was then 
normal. On admission on the present occasion he presented 
his usual symptoms and was deeply cyanosed. His nrine was 
scanty and of very high specific gravity ; it was free from 
albumen. The first time I saw him I noted that his pnlse 
was "very persistent, long, and of extremely high pressure," 
and I attributed his condition to Bright's disease. After he 
had been in a week I noticed that the pulse, though still 
persistent, had become shorter, owing, as I supposed, to failure 
of his mitral under the high pressure; on this occasion I 
fonnd that his first sound had come to resemble a presystolic 
bruit, " such as I have often heard in dilated hearts." After 
this he bad attacks of faintness and his pulse became inter- 
mittent. Rather more than a fortnight after admission his 
urine was fonnd to be albuminous, and be gradnally sank 



Chronic Bright'a D'ueate without Aihumnuria. 811 

and died io a fortDight, If this pstient had come in about a 
fortoight later than he did, he, like the rest, would have been 
excluded from this paper. 

Case 12 was a ver^ striking one, though the kidneys onlf 
webbed & oz. together, the urine was free from albumen up 
to the time of her death ; unfortunately she was only a few 
days under observation. 

Case 13 was very complicated, and was thought to be pul- 
monary. He developed jaundice while in the hospital, and his 
urine, at first normal, afterwards became slightly albuminous ; 
the aroonnt of it is unfortunately scanty. His arterial pressure 
was recognised as high, and his heart as hypertrophic. He 
had very granular kidneys, a heart of 17 oe., and, in addition 
to bis bronchitis, a gall-stone was found in the common duct. 

Case 16 is noteworthy because he had renal dropsy and yet 
no albuminuria, a condition which is by no means infrequent, 
no less than twelve examples occurring in this series. He was 
twice under treatment in the hospital. The report coDtains a 
very full and accurate record of his urine. It contuned a trace 
of albumen the day after his admission ou the first occasion, 
which disappeared the following day ; it again contained a 
trace on two successive days- during his second stay in the 
hospital. The character of the pulse, the dilatation of the 
heart, the renal dropsy, assodated with his bronchitis, make 
the diagnosis in this case undoubted, and it receives confirma- 
tion perhaps by the occurrence of albumen on these three 
occasionB. 

Gases 16, 17, and 18 are all ordinary eases of chronic bron- 
diitis and etuphysema, in each of which the heart was dis- 
tinctly hypertrophied, the apex beating one inch, one and a 
half inches, and half an inch outside of nipple line in each case 
respectively, and the signs of high arterial pressare being 
nnequivocal. The urine was very carefully watched and re- 
corded in all three caseSj and it was always perfectly normal. 

Case 19 had previonsly been in the hospital with bronchitis 
and albuminuria; on this aocasiou, though having the signs 
of high arterial pressure well developed, and the pasty aspect 
of Bright's disease, his urine was perfectly normal, though 
rather excessive in amount. 

Case 30 was a very complicated one, both clinically and 

. „Gooj^lf 



SI 2 Chronic Brighf't Duease without Albumitniria. 

pathologically ; perhaps it ought to h&ve beea excladed 
aa being doubtful, though I cannot think that any doubt 
pertains to it. The fact that the heart waa found to wngh 
17 01., without Talvalar disease, and that the arteries were 
recogniaed aa thickened by the naked eye, would fairly prora 
the existence of the vascular changes of Brighfs disesH, 
whatever the appearance of the kidney might be. I thought 
that its seetiona showed the ordinary vascular changes, though 
but slightly marked, of thickened capsules, thickened arteries, 
and thickened intertnbular tisane, together with an excess of 
epithelium, which might have beeu accounted for by the exist- 
ence of emboli in the kidney and the congestion they would 
ffie rise to. Dr. Fagge cast some doubts upon the kidney 
changes ; but the importance of these changes is a question of 
opinion, as it depends on the variation of the limit of the so- 
called normal. There were several old ante-mortem tbromtn 
in the ventricle (this is the third case in this series in whid 
they have been found) ; the condition of gangrene of his toes 
and lungs, and also perhaps the acnte enteritis, which set up 
bis peritonitis, may be accounted for by embolisms from this 
source. 

Case 31 is that of a man (proved by the post mortem to be 
gonty) affected by tubercular phthisis at the ago of sixty-five. 
He is said to have lost two brothers by the same disease. He 
had been in Guy's three years previously vrith severe bron- 
chitis, affecting the right lung most; signs of consolidstion 
were then present at the right apex ; bis urine was perfectly 
normal on that occasion, as ou this. The diseased condition 
of his radial arteries, associated with high pressure, led to a 
suspicion of his kidneys, though no hypertrophy of the heart 
could be found ; they were subsequently found to weigh 9 ox., 
to he very granular, and to contain many cysts. The heart 
only weighed 11 oz., and this leads me to remark upon the 
fallacy of expecting hypertrophy of the heart to be invariably 
present in all cases of Bright's disease. There cannot be the 
least doubt that an hypertrophied heart may atrophy, as it 
probably had done in the present case, and also that hyper- 
trophy may be prevented by impaired nutrition. I have 
repeatedly noticed a simitar coincidence of absence of heart 
hypertrophy in cases of Bright's disease in which ontriltou 



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Chrome Bright's Disease without Albuminuria. 313 

has been gravely interfered witb, as, indeed, I suppose nil 
obserrera have done. I hold, therefore, that uoder certain cir- 
cumstaDces the absence of hypertrophy in casea of high arterial 
pressure muat not be taken to prove either that the preunre 
is not or has not been high, or that organic changei have not 
been prodnced. 



III. Cotes of cerebral diieate. 

The nine caaea forming the third group are examples of 
chronic Bright's disease associated with cerebral diseaae, due to 
the changes prodnced in the arteries of the brain. Of these 
only two were fatal j the remaining seven are all well-proved 
cases of Bright's disease ; in all of them the urine was asually 
normal. As in the lung complications, fatal caaea without 
albuminnria are not very common, and thia for two reasons : 
cither the cerebral hemorrhage occurs during an exacerbation 
of high pressure coincident witb a passing renal congestion 
which gives rise to albuminuria, or else the venous congeation, 
associated with the stertorous breathing of fatal cases, is 
sufficient to cause the temporary appearance of albumen. 

Case 22 is a remarkable one ; he died of cerebral h«mor- 
rhage within twenty-four houra of his admittance; hia kidneys 
were found to be healthy as far as the naked eye could judge; 
they weighed 16^ oz. His heart, however, weighed 23 oz., 
while the valves were healthy except for the ordinary hyper- 
trophic thickening. His aorta was fairly good, but all his 
peripheral veaaels were excessively thickened, and the larger 
ones atheromatous ; his must have been a case of extravagantly 
high pressure without albuminuria. 

Case 23, another case of cerebral hemorrhage, closely 
resembles the last. His arine was examined on several 
occasions and found to be healthy, till the last two days, 
when it became mingled with blood, the results of catheteriaa- 
tion. The heart weighed only 12^ oz, ; the valvea were 
healthy, but there was very extensive and general arterial 
disease, both of large and small arteries, all of which were 
greatly thickened. The kidneys weighed 12 oz., and appeared 
healthy, but their arteries were conspicnoosly thickened. 



314 Ckromic Bru/hfi Diteate mthout AlAumimeria. 

Fortiou were pnt aside for micrOBcopical exunination, bnt 
were anfortaiiately thrown away by miitake. 

Cases 24 and 27 were faotli old men with andden attack* of 
hemipl^a, whose hearts were decidedly hypertrophied, Tenelt 
thickened, and arterial pressure manifestly high. The niine 
in each case was noroud, and a carefol record of tiie wine of 
Case 24 is giren, which extends over a long period ; it sbowi 
a considerable rariation in the quantity of solids excreted, and 
a deposit of one add crystals was frequently observed in it 

Tn Csse 25 no hypertrophy of the heart was demonatTsted, 
but his poise was remarkably long, and the artery mock 
thickened; he alio was suffning firom a sudden attack of 
hemiplegia, and his urine was albaminons for two days after 
admission ; the albumen then disappeared and was seen no 
more during the six weeks he remained in hospital. 

Case 26, another old man with similar symptoms ; he had a 
striking family history ; his father and one brother both died 
in apoplectic fits. His urine contained graaolar casts, but do 
albumen. 

I bad not an opportunity of seeing either of these eata 
myself, except Case 24 ; but the constancy with which sndda 
and permanent hemiplegia in old persons is found to be the 
result of hnmorrhage, together with their cardio-nscolar 
phenomena, make the diagnoses tolerably certaia. 

Coses 38 and 29 are well-marked cases of cerebral soften- 
ing ; in the cose of 28 the condition of the urine made the 
diagnosis too easy, for it frequently contained a trace of 
albumen, but in his case the arterial pressure seemed to hare 
reached an extreme height, and was a much more constant 
guide than the urine, which on several days was free bma 
albumen. In Case 29, also, the arterial pressure was exceed- 
ingly high, his heart was distinctly hypertrophied, and hit 
urine of low specific gravity, though it never contained any 
albumen. 

Case 80 was a patient on the verge of greater eril. She 
had lately become subject to severe attacks of vertigo, and was 
brought to the hospital in an uuconscioua state, having ftUeu 
down in one; she was unconscious two hours and then 
recovered without paralysis. Her heart was obviously hyper> 
trophied, and her arterial pressure extremely high ; her urine 



Goo^^lc 



Chronic Brigkt't Disease tcUhout AJbumimtria. 815 

vas ftlwajs Qormal, She suffered much from vertigo and 
headache, and it waa aot tlifficalt to foretell that she would 
almost inevitably suffer from cerebral hiemorrhage at an early 
data. 

The great importance of these cases is to be foand in the 
value of these symptoniB of high pressure io the proguosia 
and treattneut d£ such cases. Dr. Broadbeut has especially 
pointed out with what accuracy an attack of cerebral hemor- 
rhage can be foretold, and also how much can be done to ward 
off the evil day by appropriate treatment designed to reduce 
the high arterial pressure. 



IV. Cotes qf renal dnpsp without atitaainuria. 

This forms an unexpectedly large group, for it includes the 
nine cases in this section, and in addition Cases 16, 40 and 45. 
These twelve may be divided into two classes. The one gronp 
consistB of some rare oases of chronic renal cedema, in which 
the material exuded into the tissues is of a semisolid gelatinous 
Datore : these closely resemble the cases described as myxoedema, 
if, indeed, they are not still more intimately allied to it ; and 
they appear to form a link between the ordinary serous cedema, 
and the chronic changes described aa Rbro-hyaline thickenings 
or exudations, upon the nature of which I think they throw 
very great light. The other group consists of cases of chronic 
Brigbt't disease vrithout albuminuria, in which an exaoer< 
bation of these symptoms, which under ordinary ciroum- 
ttancea would give rise to a transient albuminoria, produces 
instead a general oedema. The reason for this is tolerably 
obvious. The conditions giving rise to albuminuria and renal 
dropsy are no doubt closely allied ; in fact, we have seen 
reason to believe that increased artoial pressure may deter- 
mine eithEir albuminuria or general adema, or more com> 
monly both. I have elsewhere pointed oat,^ that increase of 
arterial or venous pressure in the kidney produces albuminuria, 
while its reduction cures it. The same is known to he true 
of venoQB pressure in the production of dropsies, and it can 
also be demonstrated with regard to the arterial pressure. 

' 'TnDB.Ito;. Hed. and Chinirg.Soc.,' 1874; •PTactiUaam,'lB7i. 

Googk 



316 Chrome Bri^hf* Diaeate without Albttminuria. 

It is cooceiTnble that, owing to local couditioDS the kidaej'a 
may be protected from an increase of arterial pressure, 
which is BufficieDt to prodnce general cedema; this might 
be efiected by a contraction of tbe renal artery for the pur- 
pose of protecting the kidney from the strain of increued 
arterial preasnre, a strain to which it is particnlarly lab- 
ject, and which the microscope shows as produces terrible 
ravages in acnte disease. There can be no reason why 
the renal artery should be denied such a power of pro> 
tectire contraction as this, which is accorded to all othet 
arteries of equal calibre, indeed, it has been demonstrated to 
occor in the physiological laboratory by Dr. Lander BmntoQ 
and Mr. Power in their researches on the action of digitaliB. 
Another reason oiifjht be offered for the non-production of 
albuminnria in these cases, which perhaps explains its absence 
in so iarge a proportion of cases of chronic Bright* s disease, 
namely, the thickening which has token place in the vessels of 
the Malpighian tnfte, through which no doubt it is difBcult 
for the albumen to tnmsade ; and again, a third may be fonad 
in the thickening of the capsules, which most enable them to 
resist the expansion of the tnfts and prevent their tni^ditj. 
Now, it is obvioDsIy easier for blood serum to tranaade thioagh 
distended vessels than through comparatively contracted ones. 
In this resistance of the Malpighian capsules to distension, and 
the consequent strain thrown upon them in high arteriil 
pressure, we have, no doubt, a ready explanation of their great 
thickening in Brighfs disease; and in tbe resistance they 
ultimately offer when thickened and contracted, we may find 
a good and sufficient reason for the greater thickening aad 
hypertrophy of the branches of tbe renal artery than those of 
any other artery in the body ; it is undoubtedly a fact that 
thickening of the arteries is more constantly and frequently 
found in the kidneys than elsewhere. We have, then, three 
reasons to offer in explanation of the absence or small quantity 
of albumen in acute exacerbations of chronic Brighfs disease. 

1. Protective contraction of renal artery, especially tme in 
acute disease. 

2. Thickening of vessels of Malpighian tnfts. 

8. Thickening of capsules of tofts, preventing distension of 
vessels. 

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Chvnic Brighft Diteate without AliumiTiuria. 817 

It is noteworthy, also, that a similar absence of albomiDoria 
not ncrrequently occurs in the renal dropsy of children after 
scarlatina; this happens in slight cases, so far as I have 
obserredj they may possibly be explained by the protective 
contraction of the renal artery, or by the changes of the so- 
called glomerular nephritis. Of course it is impossible to 
accept the theory of the contraction of the renal artery unless 
one previously admits that Bright's disease is not a disease of 
the kidney so much as a general disease, and that the rise of 
srteria] pressure is not due to local so much as to general 
causes. 

But these speculations are comparatively idle. Let the cases 
tell their own tale. Case 31 is worthy of special notice. This 
man had a peculiar form of chronic general ledema, which was 
more solid and resistant to the touch than ordinary serous 
(edema, and was found after death to consist of semisolid, 
jelly-like material. It had not the chemical characters of 
myicedema. I saw hitn when first admitted, and, from the 
condition of his pulse and the hypertrophy of the heart, had 
no hesitation in attributing his condition to chronic Bright's 
disease, although his urine was perfectly normal. This case 
KBs one, like others in this paper, in which the cardiac hyper- 
trophy was altogether ont of proportion to the kidney changes j 
the arteries generally were thickened. 

Case 32 was one which appeared to closely resemble the 
last, bat it did not prove fatal while under observation. lu 
thia case, however, the kidney changes were probably much 
more severe, for there was extensive retinitis and severe anfemia. 

In Cases 33, 34, 36, 36, and 39, the attacks were acute, 
and resembled ordinary attacks of acute nephritis, but 
the albaminoria was absent ; it was not completely so, how- 
ever, in Case 35. In this one there was a slight trace of albu- 
men for the first two days of his stay in hospital, and the 
drops; and albuminuria went away almost together; it was 
followed by copious diuresis. All these cases might be perhaps 
open to some question, and this one moat of all, as to whether 
they were subjects of chronic Bright's disease or only of 
primary acute attacks. They were all men over forty, and this 
alone, I think, is a strong argument against primary renal 
disease, which would appear to be rare at that age, unless the 

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SIS Chronic Bright't Disease without Albumitmria. 

result of some completely new poison introduced iato the 
system, sncli as scarlatina. 

In Case 35 the apex beat could not be distingniahedj bat 
the area of dulness was said to be enlarged. This is always an 
nntnutwortfay sign, and I am villiug to abandon tbis case if 
bis age, his bloated, unhealthy appearance, and bis alcoholic 
excesses are not considered sufficient to give a fairly certain 
diagnosis of previous disease. 

Case 36, again, was a most obscure case, and the apex beat 
could only be felt with difficulty, but the marked aniemia, the 
renal dropsy, the high arterial pressure, which is well demon- 
strated by the sphygmographic tracing, all combiue to make a 
diagnosis of renal disease necessary. 

In Cases 88, 84, and 89, the displacement of the apex wai 
well marked, and the pulse highly characteristic. Case 33, 
moreover, had had one previous attack. 

The remaining cases in this group (Cases 87, 38, 15, 40, 
and 45) were all cases of a subacute nature, in which the 
patients, haviug been more or less severely ill for some time 
with bronchitis and other troubles, gradually develop renal 
dropsy instead of simply cardiac. In Case 16 the urine onl; 
contained a trace of albumen on three occasions, though it va« 
strictly watched over a long period. His appearance was very 
Epical. Case 88 is the weakest of this series, for her cardiac 
hypertrophy was not absolutely demonstrated, but the diagaosis 
is considerably strengthened by the presence of albumen in ber 
urine on three occasions. Case 37 had degenerate vessels. 
Cases 40 and 45, yet to be referred to, were both certain and 
very typical cases. 



V. Cases unih gout. 

The association of Bright's disease with goat is too well 
known to need any notice here. In the six oases presented 
in this section, the existence of well-marked gout lends 
additional certainty to the diagnosis of these cases, in all of 
which the cardio-vascnlar lesions were well demonstrated 
clinically, although none of them terminated fatally. Is all 
of them the urine has been watched very carefully, and the 



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Chronic Bright XHieate without A^minuria. 819 

obsemitions folly recorded in tables. In only one was 
albamen ever present, and then only a trace oa two occasioDs, 
The specific gravity was good in all the cases except Case 44, 
in which it varies from 1016 — 1010, though occasionally 
reacbing 1020. The records of qnantity I do not put forward 
8s absolutely reliable ; they are probably oaly approximate and 
can only be trusted as giving a minimum quantity. Case 
45, already alluded to as having renal dropsy, had very great 
and easily detected hypertrophy of his heart ; he came sub- 
sequently under observation as an out-patient, and though he 
had no atbuminnria presented most typically the cardio-vnacular 
rigns of Bright's disease. Cases 40 and 41 are further 
strengthened by the existence of plumbism, another condition 
commonly ass'odated with Brighf s disease. I am disposed to 
think that we sometimes mistake cause for effect in this asso- 
ciation. Is it not probable that in many cases it is not the 
plumbism which causes the Bright's disease, but rather the 
Bright's disease which causes the plumbism ? This view well 
accords with the danger that certainly exists in Bright's disease, 
of poisoning people with the ordinary medicinal doses of drugs. 
Their excretory organs are usually inefficient, especially when 
clogged by catarrh. 



VI. Categ with severe epittaxi*. 

The frequency with which severe epistaxis occurs in old 
people with high arterial pressure is very striking, and, for 
them, very fortunate ; for, as I frequently have occasion to 
remark, " if their noses did not bleed their brains would," 
The symptom has been commonly observed as a precursor of 
spoplety, and it is a fortunate accident which relieves arterial 
pressnre and gives warning for further treatment. In these 
three cases the symptoms of Bright's disease are well marked. 
In Case 46 there were lumbar pain, a puffy face and the presence 
of albumen on two occasions, in addition to the cardio-vascular 
signs. Case 47 had degenerate vessels, and Case 48 had 
remarkably and persistently high arterial pressure, notwith- 
standing the heemorrhage, which in most people would have 
produced very low pressure. 

D,gt,zec.yGOOglf 



Chroiae BrighfM Duease tmthout Al&uaumtria, 



VII. Ca»e$ with varioui medical and sttryieal dtMeatet. 

In the foUoving nioe cases of varioas diseases tLe urine 
was known to be asaally normal in eight ; in the ninth no 
note of the urine vas obtainable. In seven oat of the niue 
cases hypertrophy of the heart and high arterial pressure were 
recognised during life ; in one no note is made on the matter j 
in another. Case 50, the report was not available for reference 
at the time of writing. These cases point strongly to the 
importance of carefiil examination of the arterial pressure before 
any operation is attempted on a patient, though it does not 
appear that Bright's disease without nephritis is so dangerom 
an enemy to the surgeon as it is when nephritis is also preeent. 

Case 49 was always suspected of Bright's disease, though it 
was never thought to be proved against him. The diaplice- 
ment of the apex was recognised and recorded ; his urine 
contained albamen at one time, but he waa undetgoing 
catheterism, and the nrine contained pas, which probiiblf 
accounted for the albumen. The most remarkable feature in 
the case was the severe pericarditis, which failed to produce s 
hmit ; the patient was examined by Dr. Goodhsrt a few days 
before death, and he only heard an indistinct first soand, 
although the whole pericardium was found to be covered with 
shaggy lymph. 

Case 50 is of interest because the urine was repeaiedlj 
examined and found to be normal, so that no Bright's diseue 
was suspected, but an attack of acute nephritis during cod- 
valescence proved fatal, and it was then found that chronic 
disease existed. 

Of the next five cases (51, 52, 63, 54 and 55) all pre- 
sented typically the cardio>vaacular signs of organic disesK, 
nnmely, displaced apex beat and high arterial pressure. In 
Cases 51, 52, and 53 the urine was always normal; Cnee 51 
was diagnosed during life aod proved by post-mortem esami* 
nation. The heart hypertrophy was very well marked in liie 
other two cases. 

In Case 54 the aitcrial pressure was so high that I was 
led to remark that 1 was convinced that he had Brighfs 
disease, and if he was exposed to a chill bia urine would rery 



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Citrbnic bright** Pitease toithout Albuminuria. Sjli 

probably become albuminous. It bappeoed soon after tbat 
he went down into " the park " on a very cold day, and the 
following day albumen was found in his nrine; it only 
remained present for three days, and then entirely disappeared. 

Case 55 also confirmed the diagnosis by once presenting a 
trace of albumen, but the report is not a very satisfactory one. 

Case 56 is a very interesting one, though it lacks confirma- 
tion. It is the case of a woman who suffers from extremely 
severe attacks of vomiting and pyrosis, during which she can 
keep no food whatcTcr in her stomach ; these attacks last for 
Tariable periods, from a few days to a few weeks, and then pass 
off leaTing her in her usual health. She had a pulse of 
extremely high pressure, a very unusual degree of it; her 
■phygmographic tracing shows its characters well. She was 
admitted into the hospital three times, and on the second 
occasion a diastolic bruit was distinctly audible in the aortic 
area; this faded somewhat while she was io, and at the time 
of her next admission I could not detect it. I believe in this 
case temporary aortic regurgitation occurred during an extreme 
elevation of pressure; it probably indicates a considerable 
degree of aortitis deformans. I have heard temporary aortic 
regni^tation take place in two other cases, and a short time 
ago some similar cases were reported from the Continent; it 
is probable that it not unfrequently takes place, I once had 
an opportunity of examining a case similar in many respects 
to the present one. I was asked to perform a post-mortem 
examination on a gentleman whose case had caused much per- 
plexity to three or four of our most distinguished physicians ; 
he bad had attacks of vomiting, with intermediate returns to 
health ; like the present patient, his urine had been repeatedly 
examined and prODOUOced normal. During a very severe and 
prolonged attack he died from exhaustion. Before the examina- 
tion, after hearing the history I ventured to suggest chronic 
Blight's disease, and was told that this had been excluded by 
the condition of the urine, I found, however, typical red 
granular kidneys and a hypertrophied heart ; this occurred five 
fears ago. 

Case 57 has been introduced here to prove a point. 
Although no record can be obtained of his urine, it may 
fairly be assumed to be normal, for his health was good 



332 Chronic Br^ht's Disease without Albuminuria. 

and his kidneys were practically healtby ; but his heart 
was nevertheless greatly hypertrophied, weighing 18^ oz., 
although the valves were healthy. There was thickening 
of the arterioles of the pia mater, as well as of the arteries 
in the kidney; the kidney showed a little excess of stroma 
and some degeneration of Malpighian tufts. Dr. Fagge 
appends the note : " I think this case is distinctly opposed 
to the view that cardiac hypertrophy is secondary to an 
advanced degree of kidney disease." This case does not stand 
alone in this paper, nor is it even the best example of its clasa. 
In Cases 6, 22, 23, and 31, the kidneys presented very slight 
changes, and in all there was more or less hypertrophy of the 
heart; these organs weighed 33 oz,, 22 oz., 12| oz., and 15 oz,, 
respectively. Case 6 is a case of failure of the heart from 
high pressure, without valvular disease, and with general 
thickening of the arteries. Case 22 is a case of cerebral 
biemorrhage also, with general arterial thickening. Case 28 
was of the same nature, and Case 81 was the case of chronic 
renal cedema, with very slight kidney changes. These cases 
taken together almost conclusively prove the point, that there 
is such a thing as a disease with high arterial pressure and 
general vascular changes which is not secondary to disease of 
the kidney, hut must be regarded as a general disorder. 
Inasmuch as we can trace the most gradual development of 
kidney changes in such coses, and we meet with every grade 
of kidney from the healthy to that of extreme disease, it is 
difficult to know where to draw the tine that shall separate 
arterio-capillary fibrosis from Bright's disease, especially when 
we consider that these cases start with a certain functional 
disorder, and that their natural tendency is to go steadily, 
but surely, on to advanced kidney disease. I feel convinced 
that the more carefully the cases I have here collected are 
studied, the more certainly must it be impressed upon an im- 
partial mind that we are here dealing with various phases of 
one common disease, and that its beginnings and endings are 
Boch as these cases indicate, 



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Chronic Briyht's Siseate without AlbumiHuria. 323 



VIII, — Caiea with well-marked albuminuria, which wa» variable 
or ditappeared entirely. 

This last group of cases I hare introdaced to make plain 
another point. So far, cases have beea quoted to sboir that 
the red granular kidney does not give rise, under ordinary 
circumstances, to albuminuria. Not only has this symptom 
been occasionally absent, but it has been usually absent and 
only eiceptionally present, I do not, however, wish to ignore 
the fact that a large proportion of our cases of granular kidney 
have albuminous urine, and that these were the cases which 
Bright recognised and described ; I only desire to draw a line 
between the red and the yellow, or mixed granular kidney. 
ChnicaUy, the red kidney has commonly normal urine, and the 
yellow Iddney has commonly albuminous urine ; while patho- 
Ic^cally the red kidney has interstitial and vasoular changes, 
* while the mixed kidney baa added to these epithelial changes, 
Now, it is the natural tendency of the red kidney to develop 
on small provocation tubular changes, and thus to become the 
yellow or mixed; it is these cases that are commonly recog- 
nised by the condition of the urine. If the attack is a slight 
one, the tubular changes may clear up again, as they do in 
scarlatina and other acute conditions ; while if it be severe, 
the patient will go more or less rapidly down hill till he 
mcbes death. 

Cases 68 and 59 well illustrate the last remark. Case 58 
is an undoubted case of chronic Brighf s disease, for she has 
bad two previons attacks of renal dropsy, and now comes 
nnder observation with the third ; the first when she vaa fifteen, 
thesecoad when twenty-eight, and she is now forty-three. The 
hypertrophy of her heart is not well marked, but her arterial 
pressure is exceedingly high, and altbongb all her dropsy dig. 
appeared and her urine became normal, she can hardly be 
thought to have escaped with healthy kidneys. No doubt in 
her case the disease falls more on her kidneys as a local 
disease, and less on the system generally, than in most cases 
of the chronic disease. Supposing that she bad much epithelial 
change in her kidney, as no doubt she had, the change from 
albomiuuria with severe dropsy, to normal urine, was clearly 



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82+ Chronic Briphft iHteate vntkmt Albuminuria. 

too quick for the epithelium to have recovered itself; it must 
then have still been much diseased while she was again passing 
normal uriue ; so that here probahly we have a case of the 
mixed or yellow granular kidney in process of clearing up, 
and passing urine free from albumen. But this urine is not 
like that of most of our other cases; it was urine of low 
specific gravity (ranging latterly from 1013 to 1014), and 
answering to the description which is usually given of the 
nrine of granular kidney which may be free from albumen, 
bnt is said to be of low specific gravity and of large qnantity. 
This is the sort of case upon which such observations have 
been foonded, and it is important to recognise the fact 
that when the specific gravity is low the kidneys are really 
seriously aSiected, that they belong to the mixed or yellow 
variety. 

Case 59 shows a similar kidney going in the opposile 
direction, not towards recovny, but towards death ; here there 
has been a temporary disappearance of albomen, but it returned ' 
again and was present when she was discharged. In this 
case the specific gravity was still lower, generally about 1009 
or 1010, only once reaching 1016. In this case also, retinal 
hemorrhages were present, a condition, as far as my experience 
goes, chiefly associated with chronic and sevese kidney disease ; 
I do not ever remember to have found them present in what 
I shonld call " chronic Bright's disease without nephritis." 

Case 60 is another case with freedom firom albumen, occur- 
ring in a case of manifestly bad kidney. The patient was 
sixty years of age, recovering from an attack of acute nephritis 
with dilatation of the heart ; probably his cardiac condition, 
and the venous congestion it induced, accounted for the high 
specific gravity of his urine. - 

Case 61 shows a remission of albuminuria during an acute 
attack, and while the kidney was obviously much diseased. 
The presence of blood in the urine and the dropsy indicate that 
it was really a severe acute attack, yet in the course of his 
illness his urine would be free from albumen on one day, and 
bloody on the next. These relapses seemed to be determined 
by leaving his bed ; while he stayed there he would do well ; 
when he got about the albumen returned. 1 have remarked 
on this more at length in the record of his case. These cases 

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Chronic Bnght'a Duease withotU Al&umtmtria. 325 

appear to indicate that the mixed granular kidne;' may pasa 
noD-albnmiDoai orine, bat that it will probably be of low 
specific gravity. 

While describing the red granular kidney as often becoming 
the mixed or yellow, variety, I do not wish to maintain that 
this is by any means the invariable course of events, I 
am only indicating one mode of termination of what I take to 
be the ordinary coarse of the most chronic form of Bright's 
disease. On the other band, there are many other ways by 
which the mixed granular kidney can be reached. The 
disease may commence as an acute affection and afterwards 
become chronic, it may commence as chiefly epithelial and 
terminate as chiefly interstitial ; again, it may be chronic and 
epithelial, or acnte and interstitial What has been cause in 
one case may be the result in another ; thus general disorder 
may cause high arterial pressure, and this, in its turn, kidney 
changes ; while, on the other hand, kidney changes may be 
primary and acute, and they may in their turn produce 
imparity of blood, and this general high pressare. Bnt 
whether ve read the tale backwards or forwards it is the same 
tale in the end, it is concerned with the same events, we only 
become acqnunted with them in a different order ; thus, we 
see chronic prodnce the acute disease or acute disease produce 
the chronic; if we know the beginning we can generally tell 
the ending if they live ; for those which begin in the tubes 
end between them, and those which begin outside end within 
them. 



CASES. 

I. Casks of Hkart F&ildbe, 

Cask 1. Hyperlrophied heart ; aortitis d^ormatu; thick 
arleriet ; large granular Hdneya ; very rare trace of albumen ; 
<fca*A.— George C — , set. 58. Dr. Wilka (Clin, clerk, Mr. Lang- 
ridge). Admitted March 11th, 1879; discharged April 26th, 
1879 ; readmitted July 16tb, 1879 ; died September 17tli ,1879. 
A horse-keeper, formerly a soldier, served through the Criinea. 



326 Chronic Bright's Disease without Alhumimtria. 

No family history obtainable. Measles, scarlatina, and Tuiola 
in childhood ,* syphilis twenty years ago. Had what he calls 
" rhenmatic ferer " in Turkey, but his joints were not swollen. 
Has drunk spirits freely. Six weeks before admission he 
became troubled with a feeling of fulness and soreness in the 
cheat, his breath became short and laboured, and he suffered 
from cough, These symptoms lasted for three weeks, snd 
then improved ; they recurred a few days previoua to admissioa. 

Od admission the patient was suffering from great djs- 
pncea with congh and bloody sputa, and great lividi^ t£ 
countenance. A quantity of blood was immediately abstracted 
from the left median basilic rein (aboat 18 oz.) with almost 
instantaneous relief to tbe patient, who was then propped up 
in bed in the sitting posture, this being the most comfortable 
to him. He is a powerfully-made man, with large square 
head and strongly-marked features. WelUmarked subcon- 
junctival oedema, but face not otherwise puSy. Tbe report 
makes no mention of the presence or absence of dropsy. His 
face has the aspect of considerable distress from urgent ortho- 
pnosa and apnoea. He has a good deal of congh and the ex- 
pectoration is now thick and uniformly tinged with blood. 
The breathing is chiefly abdominal, the chest somewhat barrel- 
shaped and uniformly resonant. There are mucous riles over 
the whole chest, moat abundant on the right side. A smsll 
amount of albumen is present in the urine. On the day of 
admission I made the following note : — " Apex beat greatly 
displaced, two inches external and two and a half inches below 
nipple. To-and-fro bruit over aortic valves. PvUe persistent. 
Venels thick. Fulse is now splashing, probably due in great 
measure to the bleeding. Chronic Bright's disease ; aortitis 
deformans ; perhaps some valvular disease ; severe bronchitis." 
He presented typically the pulse of high pressure, and I fre- 
quently pointed him out as a good example of its results. 

Unfortunately the report contains do further note concern- 
ing bis urine during tbe whole period of his stay in hospital 
on this occasion. On March 17th the note runs : — " la much 
better this morning, has not so much difficulty of breathing. 
The rftles are not so many nor so loud on the right side of tbe 
chest; on the left there is ^Ight tubnlar breathing." The 
correctness of the last observation is open to question. 



chronic Brigkt's Diseate without Albuminuria. 327 

April 3rd. — Patient usually wakes doriag the niglit with great 
pain in the epigastrium, uanaea, but no sickneBs. Is obliged 
to get up aud walk about the ward. The pain extends up into 
Ute right shoulder. On April 7th he is taking out-door exer- 
ote; on the 16th he has a slight relapse ; on the 26th, haviog 
completely recovered from hia bronchitis, he leaves the hos- 
^tal ; the double aortic bruit can still be heard at the base 
plainly. 

On July IGib be is readmitted with a return of his former 
symptoms. A few days prerionsly he had taken a fresh cold 
and had spat blood ; he said that his hands were swollea, bat 
there is no oedema of either hands or legs at time of readmis- 
rion. He is ansemic ; he is no longer described as cyanotic. 
The signs in his chest are much as formerly, but there is now 
some dnlnesa at the base of both lungs behind, and moist 
sounds are more abundant over the back. The apex beat is 
stated by the cterk to be one and a half inches to the outer 
side, and two inches below nipple (half inch less in each direc- 
tion than Iformerly noted). Heart's action irregular. Thereis 
a double bruit heard over aortic valves, and a systolic bruit heard 
at apex which can also be heard in the axilla but not at the 
angle of the scapula. Area of cardiac dulneBs increased. 
Fnlae, 80, persistent aod irregular; it appears.amBll and feeble 
when the arm is depressed, but when the arm is raised the 
pnlae is full and suddenly collapses under the finger. The 
liver dnlness is enlarged ; lower edge of liver can be felt about 
two inches below the ribs ; there is tenderness on pressure in 
the epigastric region. An accoant of the urine is tabulated 
below. July 19tb. — Was obliged to get out of bed about 
8 a,m. on account of difficulty of breathing; the attack lasted 
an hour and a half; has pain in the chest. Feet swollen this 
morning. Daring the rest of July and August he continues 
in much the same state, with increasingly severe pulmonary 
and cardiac dyspnoea ; though his feet are much swollen, he 
had no (sdema of his face or upper extremities. His urine 
continued &ee from albumen all the time. He suffered much 
from paroxysmal nocturnal dyspnoea, for which he was treated 
with morphia injections. Sept. 3rd. — Has had a very bad 
night. Dyspnoea extreme. This morning he has been expec- 
torating mucus tinged with blood. Heart's action is very 

. „Gooj^lc 



S28 CArottic Bright'* Dueate v>ithout Aibuminuria, 

excited. To-and-fro bruit very distinct at apex. Was bled 
to 4 OB. with instant relief. He onljr paased 10 oc. of urine, 
of high specific gravity, in the past twenty-foar hours ; this 
was increased in the following twenty-four hours to a pint. 
Sept. 10th. — His legs are so extremely cedematous that 
fluid is exudiog from the distended skin. His breathing is 
becoflaing more di£Scalt. The urine on standing stains the 
glass ; there is a thick deposit, which od micrOBCopical exami- 
nation proves to contain phosphates, mucus, and ddbrtt of 
epithelium. Sept. 15tli. — Dyspnoea is extreme. Pulse ex- 
ceedingly weak and very irregular, so that one cannot count 
the beats. Legs have been pricked, and a quantity of fluid 
has escaped, but the skin is becoming of a mottled character, 
and patient has a worn and anxious expression. On this day 
his urine became albuminous. He died rather suddenly two 
days afterwards. 

DiU. QouUtr. Sp.p. SoUl*. Alb, 



,• 


.. loss ... 


— 


None. 


seoi. . 


.. lOlfi .. 


840 


AttMeP 


60, . 


— 


— 


— 


88 „ , 


... 1028 .. 


. 1064 ., 


,. None. 


80,. . 


,. 1084 


720 


,. 


20. 


... 10B6 ,. 


620 .. 


» 


10 „ . 


.. lOSO .. 


300 .. 


.. 


10 „ 


— 




— 


1*.,. 


.. 1030 .. 


860 .. 


. None. 


u „ 


.. 1032 


984 


.. 


— 


.. 108> .. 


— 


— 


10, 








M., . 


.. 1080 .. 


mo ., 


_ 


BO „ 


.. 1080 - 


600 ., 


„ None. 


U ,. 


.. 1080 .. 


420 ., 


.. 


8„ . 








10 „ 


1040 


400 ., 


NODO. 


8 » 


1026 .. 


800 





16 

Post-mortem report (by Dr. G. F. Crooke, house-physician). 
—Face pale, jaundiced, Hvidity .of lips, capillary injection of 
cheeks. A well-formed man, but coasiderably wasted. 
(Edema of feet, ankles, and thighs. Brain normal. Lungs, 
upper and middle lobes, crepitant, considerable emphysema 

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Chrome Bright't Diteate without Albuminuria. 839 

and bronchitis ; lower lobes tongh, indurated, and cedema- 
toDB. A good deal of mnco-porulent secretion in bronchia. 
A small infarct in upper lobe and a large one in lower 
lobe of right long. Pericardium somewhat thickened, 
containing a considerable qaantitjr of serous fluid. A patch 
of recent pericarditis on left ventricle. Heart 27 os. All 
cavities more or less dilated. Pulmonary and tricnspid valves 
normal. A widened mitral orifice, easily admitting four 
fingers; valves geoerally thickened and contracted. Aorta 
studded throughout with calcareous spicules and plates ; valves 
thickened, puckered, incompetent ; likewise containing im- 
bedded in their cusps calcareous spicules, especially down the 
centre of each cusp. Heart muscle (left] toughened from 
more or less fibroid induration. The endocardium thickened 
more than normal. Well-marked aortitis deformans, more 
particularly in ardi and thoracic portion. Radials thickened 
and homy in places. Stomach and intestines congested. 
Liver 65 oz., shape normal; localised patchy thickenings of 
capsule, with bands extending into parenchymatous tissue. 
Liver tissue firm, cuts toughly, shows the nutmeg characters 
fsirly well. Spleen 5 CH-j tough and small. Kidneys, 12 08. 
Right presents a more congested appearance than left on sec- 
tion ; left presents a diffused yellowish colour, fatty changes 
more evident than right, both, however, were tough and firm, 
cutting with a rasp j capsule removed with difhcuUy, leaving 
a torn surface. The small arteries thowed out plainly on sec- 
lion in both kidneys ; all seemed more or less thickened, 

Plate I represents a drawing from a section of this kidney ; 
the specimen shows great intertnbular thickening of a fibro- 
hyaline nature, chiefly due to thickening of the basement 
membrane. The Malpighian capsules are much thickened. 
There is much hypertrophy of the muscular coat of the 
arteries and thickening of the intima and some of the adven- 
titia. The epithelium of tubes, where it has not fallen out, 
IB very grannlar and irregular, rather excessive in amount. 
No small-celled growth, indicative of inflammatory changes, is 
visible. This kidney shows fypically the effects of prolonged 
high arterial pressure, with slight, and probably recent, catar. 
rhai changes. 

Dig lized^y Google 



330 Chrome BrigWt IHteate without Albumhttiria. 

Cask 2. Hypertropkud heart ; aortUU deformtau ; aerHc 
r^urgitalum ; mmUipIe ameurinu ; thick vessel* ; sUghtb/ 
ffTiamlar tudmegt; urine nonnal; death. — Richard R — , et 
48. Dr. Wilks [Clin, clerks, Mr. Scott and Mr. Oarrud). 
December 8th, 1879— July 22nd, 1880. Family history ud- 
known. Wat a valet till twenty>eight years of age, after 
that a lighterman. 

Has had no prerions illneases ; no syphilis or rheumatiiD. 
Hia wife has had two children and no miscarriages. Hii 
illness commenced two years and a half ago, with a sudden 
pain in hia cheat coming on during a hard day's work, on- 
loading a ship of wheat- Daring an effort he felt a saddeo 
rick in his chest ; he felt immediately very weak and fsiot, 
and had to sit down. He has never been free from pain since. 

It is unnecessary for the present purpose to follow in detail 
the most excellent report that is given. SafBce it to eay that 
he has suffered terribly and constantly from tbe most perns- 
tent angina pectoris I have ever witnessed. His life was only 
made possible by the relief he obtained from the constant use 
of nitrite oC amyl ; of this he had a large bottle, Trom which 



be inhaled frequently. He had a paroxysmal coagh, and a 
8ee-«aw bruit in aortic area ; the heart's impulse was in nipple 
line and four inches below it. At apex the systohe broit 
was most marked. There were no physical signs of anenriio 
beyond deficient entry of air into right lang. His nrine «u 
clear, and of good qaantityj sp. gr. 1015, acid, no slbn- 
men, no sugar. He was discharged on January 26th, and 
readmitted on July 7th, 1880, The angina was now «one 
than ever. He was propped up in bed, anffering conataotlf 
recurring paroxysms of pain. He bad the typical aneunimii 
cough and loud atridulons breathing. He had some difficult 
of swallowing. His palse, which is unequal in tbe t«o 



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Chronic Bright') Diitate without Albttmtmria. 331 

radiala — ^the left being the foller — is peniatent and bearing in 
chtracter, one evidently of high arterial pressim. Urine, sp. 
gr. 1018, dear, free from albnmeD, He steadily became 
worse, having several fits of choking, and died, after a stru^Ie 
of terrible agony, on July 22ad. 

Poat-mortem (by Dr. Chwdhart). — "Extreme emphysema 
of longs : — a general disease, shown by ailkiness, irregnlar 
lobulation of the lung, aad pitting on pniBsnre. The right 
middle lobe wa* solid, of a dark dull red, and over a solid 
groaad were spread granolar lobnles, showing the bronchial 
origin of the pneumonia. The bronchial tubes were generally 
dilated, and full of thick gelatinous pos. There was no 
eridence now of any pressure upon the tubes by the aneuhsm. 
The lumen was not narrowed anywhere, nor was there any 
ulceration. Heart, 16 or 17 oz. Left Tentricle much hyper- 
tropbied and dilated ; the aortic valves had thick roonded 
edges, bnt were not very bad. The mitral had also a much 
thickened edge. The aorta was extensively diseased; it had 
nomerons sneurismal ponches, which need not here be de- 
scribed ; they extended all along the upper border of the arch 
from the ascending to the deacending arch ; there was also a 
considerable dilatation of the thoracic aorta. The sinnses of 
Valsalva were all thin, grey looking, and dilated into pouches. 
The kidneys were granular on the sarface." AbdomiiwI vis- 
cera all normal. The vesteU were very thick. 

Case 8. Hyperlrophied heart with dilatation ; aorfiti$ de- 
formtm* ; mitral regurgitation ; no valve dieease ; large 
gramtiar kidneys ; urine normal; (feaM.-~Louis D — , et. 61. 
Dr. Pavy (CUn. clerk, Mr, Hine). October 10th, 1878— 
January 7th, 1879. Readmitted May 1th. 1881. Died 
May 11th, 1881. His father is living; motliftr died in old 
age. He was a cook. He had an attack of rhenmatio fever 
thirty years ago, but no serious illness since till ten months 
ago, when he was admitted into Chiy'a for bronchitis j this was 
about the beginning of 1878. After that time he was never 
we]], constantly suffering £rom bronohitis and cardiac dys- 
pnoea. He used to sit up in bed, suffering from much dyspncaa, 
and constantly complaining of the oppression on his chest and 
liis want of breath. He had the expression of cardiac dis- 



332 Chronic Bright'* Di»ea$e without AUmmiauria, 

tress. Uis chest expanded very badty, and there iru harsh 
bronchitic breathing, with occasionaj rbonchus and noisy 
prolonged expiration all orer the chest ; at the bases behind 
resonance was impaired, and there were some moist sounds. 
His cardiac impulse was masked by hie empbysematotu lung; 
the action was irregular ; there was a syatolic faroit to be 
heard at the apex. His palse was very irregular, 66 per 
minute at the time of admission, and it was remarkably per- 
siatent, long, and incompressible. The temporal art^es 
were very prominent and tortuous, and his radials could be 
traced np the arm for some distance as an irregular cord. 
Urine, ap. gr. 1020, no albumen, no sugar ; he often had a 
trouble to hold his water, 

I r^atered the case on his first admission as one of 
chronic Brighfs disease, with bronchitis, dilated heart and 
mitral regurgitation, and was constantly in the habit of 
pointing him ont as a case of chronic Bright's disease without 
albuminuria, who showed in a typical manner the results of 
high arterial pressure ; unfortunately, no further note occurs 
in this report about the condition of the urine, although I 
believe that it was frequently examined. 



After he left the hospital on the second occasion he wis 
for a long time an out-patient under Dr. Taylor, and I saw 
him on several occasions, his condition remaining the same. 
On his readmissiou on May 4th, 1881, his case was reported 
by Mr. H. E. Richardson, and his symptoms were as before, 
but much exaggerated and intensified ; it was evident the end 
was very near. His dyspnoea was now extreme. The apex 
of the heart could be made out with much difficulty a quarter 
of an inch outside nipple line. There was a lond, blowing, 
systolic bruit at apes. Pulse 75, radial artery tortuoui, 
easily moved about, hard ; pulse incompressible. Liver ii 
now somewhnt enlarged. Urine a yellow colour and clear, 
with a white deposit at the botton of the glass ; sp. gr. 



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chronic Brigh^a Diteaie without Alhumnuria. 88^ 

1020, alkaliiie, uo albumeD, uo sugar. On boiling a 
vhite precipitate is thrown dovD, which clears up on adding 
an acid. The precipitate at the bottom of the glasa alao wilt 
not disappear on boiling, but clears up on adding an acid 
(phosphates). 

Maj 7th.— Urine a deep yellow colour, sp. gr. 1032, no 
albamen, no sugar, no blood, contains a quantity of phos- 
phates. A tracing of the pulse fails to demonstrate the high 
arterial pressure recognised by the finger, as the systolic 
eipansion, which should be prolonged, is shortened by the 
existence of free mitral regurgitation. On May 7th he deve- 
loped Cheyne-Stokes' respiration, which was observed on 
WTcral occasions by the house-physician. On May 10th, the 
day before his death, his urine, which was of sp. gr. 1025, 
and very scanty, contained a trace of albumen for the first 
time. 

Po»t-mortem (by Dr. Carrington). — Heart very large, 
veighiog 27 ozs. ; some fluid in pericardium. Hypertrophy 
and dilatation of both ventricles. All the valves quite 
healthy, except that there were one or two patches of atheroma 
on the anterior cusp of mitral valve. Cusps not thickened. 
A quantity of mnco-purulent matter in the trachea, the car- 
tilages of which were much ossified. Lungs empbyaematous, 
and the tubes much dilated. There was a good deal of pus 
in the smaller tubes, especially of the right side ; there was 
also genera) cedema of the laogs. There was pleuritic effu- 
aion on the left side and a small patch of lymph on the right. 
Lower lobe of right lung collapsed. The aorta and all 
the arteries were very atheromatous. Numerous dissecting 
aneurisms in aorta, into some of which a probe can be 
passed for a quarter of an inch. Kidneys large and coarse ; 
they weighed together 20 oz, ; tbey were granular and 
intensely congested (by mode of death) ; they appeared to 
beloDg to the large granular variety and likely to show much 
interstitial change. Arteries very much thickened. Liver 
congested and rather fatty. The arteries at the base of the 
brain were extremely atheromatous. There were some 
patches of softening in the brain. 

Case 4, Hypertrophied and dilated heart; ejffvsion into 

. „Gooj^lf 



834 CStnme Bright'a DUeaae mikout Albuminuria, 

perieardium ; aoriilit dejormant ; thick veuelM ,- muUi grammar 
kiAtega ; urine normal ; death. — William H — , set. 66. Dr. 
FsT7 (Clin, clerk, Mr, Bayer). Aagnst 2Dd — Augast ISth, 
1878 ; died. His father and mother both died between for^- 
five and fifty, cause unknown in both caaea. He is a lighter- 
man, bat haa done no vork for the last eighteen months. He 
has been a tolerably healthy man. He had typhoid ferer in 
1861. He has had jaandice once, if not twice. Has been a 
fairly sober man. He states that twelve moatha ago he had 
pleurisy, first of all on right side, then on left ; after this be 
had infiammatiOD of the lungs followed by bronchitis; whilst 
lecorering from these attacks he noticed that his feet and 
ankles were sweUiug; this extended gradually to'Iegs, thighs, 
external genitals, and finally to the abdomen ; he has been 
under medical treatment for the five months prenous to 
admission. He lies most at ease on his back. There is 
oedema in the parts mentioned and below his conjauctiva. No 
•nlargement of liver or spleen. No cough or difficulty of 
breathing. Bight side of chest hollow below clavicle and 
flattened ; it moves less than left. Dnlness on percussion over 
light long, resonance fair over left ; a few moist sounds at 
right base behind. Apex beat of heart not to be seen or felt. 
Hewt sounds distant and rough ; the heart sounds are more 
distinctly heard on right side of sternum than on left, as if 
the heart were drawn over. Radial poise small and feeUe, 
120 per minute. 

August Srd. — Patient does not pass his water in huge 
qaantities; sp. gr. 1018, no albumen, so sugar. Temp. 98*5°; 
pulse 128. August 5th. — Twenty-eight ounces of orine dur- 
ing last twenty-four honis; sp. gr. 1018, no atbnmra, no 
sugar. August 7th. — His breathing is very difficult. Pulse 
182 and very feeble. His abdomen has increased three quarters 
of an inch in circumference, measuring now for^-one and three 
quarter inches. August 9th. — ^Urine 28 oa., of sp. gr. 1016, 
no albumen, no sugar, reaotion acid. August 12th. — Diarrhcet 
came on severely, he rapidly sank, and died the next day. 
No accurate account of Uie condition of the pulse is given in 
the report, but I find from my registration book that I 
diagnosed chronic Bright's disease at my first examination. 

Poit-mortem (by the house-physiciaD). — " Much geoersl 



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Chronic Bright'g Diieaae wiiAoul Albuminuria. 886 

(Bdema. Right pleura firmly adherent all over chest wall, bo 
that InngB could only be removed with difficulty. Fluid in 
the left pleural ca?ity. Lungs bulky, in parts emphyaemfttoas, 
rather firm, and very oedematous, frothy serous fluid exuding 
everywhere apon section. Larynx healthy, cartilages very 
much oasified. On opening chest, pericardium was seen to be 
distended with fluid,- occupying a large portion of firoot of 
cheat. Heart could be easily moved about in it. Sac con- 
tuned 84 oz. of clear, straw-coloured fluid. Heart, 27 02,, 
enormouflly increased in size. Muscular fibre pale, soft, 
friable, and fatty. Coronary arteries rigid. Left auricle 
dilated, ventricle hypertrophied. Mitral valve healthy. Aortic 
valves acted well and did not allow reflux of blood, central 
valve had thickened margin about an eighth of an inch from 
upper surface, as if it had been bent on itself dnring life, 
lUght ventricle much dilated. The whole of the ascending 
aorta and arch was mnch dilated and in an advanced state of 
atheromatous change, there being large calcareous plates in the 
wall of the artery. Peritoneal cavity contained a large quantity 
of ascitic fluid, surface of intestines dull and smooth, with 
lymph in places. Liver 69 oa., showing well<marked charac- 
teristics of nutmeg liver. Spleen 11 oz., firm and hard. 
Kidneys 9 oz„ small ; capsules adherent, surface granular. 
On section, cortex wasted, arteries rigid, and standing out on 
tbe section as easily defined round tubes." 

The following case I ought perhaps to exclude from this 
paper ; its value is very greatly diminished by the omission of 
the clinical clerk to record the result of each examination of 
the urine; its condition is only described at the time of 
admission. I feel confident that many other examinations 
were made, as I have it noted in my private note-book as a 
particularly striking case of Brigbt's disease without albu- 
minuria. 

Cask 6, Hyptrirophied heart; aortitis deformatu; thick 
veueU; tmaU j/ranular Hdneyti urine normal t death. — 
Chas. B. E— , set. 68. Dr. Wilks (Clin, derk, Mr. F, James), 
April 24th— June 22nd, 1878. He is a French interpreter, 
has been a seaman. Has taken spirits freely, chiefly brandy. 
Had ague when a boy, and was sul^ect to it until he was twenty- 



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886 Chronic Brigk^i Disease vnlAout Albuminvria. 

one years old. Has never had rheamatic or scarlet ferer. 
Twelve months ago went out of his mind and was in \V'andg- 
vorth Aaylnm two montha. For the last fire months he bu 
had a cough, with oppression on his chest and difficulty of 
breathing. Ou the morning of April 19th he noticed that hia 
l^a were much swollen when he got up. Hands and eyelids 
were slightly swollen. He is a tali, stout-looking man with 
grey hair; capillaries of cheeks congested. Great csdema of 
lower extremities, none elsewhere. He cannot remain long in 
the recumbent position without attacks of apncea and binting 
coming on ; when he sits np to breathe the attacks pass oS. 
No marked physical signs in lungs, though the breathing is 
hurried. Cardiac dulneas increased. Apex to left of nipple 
and half an inch below it. Heart sounds irregular and 
tumoltnouB. Second sound appears dull at lower part of 
steraam. Pulse irregular and fast, 110. No palsation of 
jugulars. Liver slightly enlarged. Spleen normal. No 
ascites. XTrine acid, dark straw coloured, sp. gr. 1020, a mncoua 
cloud, no albamen, angar, or blood. April 25tb. — Has 
frequent attacks of half fainting. Breathing harried, hnt 
easier when body and chest are raised. April 80tb. — I made 
the following note: — "There is a distinct, short, diastolic 
bruit heard over a very narrow area between the second costal 
cartilages ; sounds elsewhere dull and similar in character. 
No thrill. Pnlse persistent but splashing during systole," 
During the remainder of his illness his chief symptoms were 
oppression and pain in the chest, attacks of fainting, purpura 
of the legs, and delirium both at night and by day. His face 
became pale, and subsequently be had jaundice (May 28th), 
with irregularity of the pulse; and for the last month he passed 
his urine and fsces involuntarily. 

Post-mortem (by Dr. Fagge). — "Braiu waated, membranes 
opaque, arteries atheromatous. Lungs very oedematons. 
Heart 30 oz. ; mitral very good ; aortic valves generally 
soft and flexible, but one had its edge rounded and thickened, 
and was to some extent shrunken. Heart's muscle good; 
aorta in extreme degree of aortitis deformsna. Liver not- 
megged, rather fatty ; splenic capsule very opaque with plates 
of cartilaginous hardening ; its tissue also hard. Kidneys very 
granular and extremely wasted, although their weight is set 

. „ Google 



Chronic Sright'a Disease without Albuminuria. 33? 

down at 10 oz. Renal arteries almost choked by atheroma. 
No gout," 

Case 6. Hypertrophied and dilated heart ; presystolic bruit ; 
no mitral disease; kidneys very sHghtly granular; arteries 
thick; urine normal; rfeo/A,— Richard M^, »t. 47. Dr. Pavy 
(Ciin. clerk, Mr. E. A. Starling). April 80th, 1879. Died 
July let, 1879. A groom. Father has had " rheumatiBm." 
One brother died with swollen legs at the age of fifty-three. 
The patient had rheumatism twelve years ago. Has had a 
winter coagh for some years; has drunk freely both of beer 
and spirits. A month ago had a severe cold and congh, from 
which he got better j a fortnight ago had a return of both; six 
days ago he noticed his legs were swollen, and the day before 
admission his scrotum became oEdematoas. He is a well-made 
and well-nourished man, somewhat plethoric and heavy looking, 
cheeks red, and venules dilated and varicose. There is sub- 
conjunctival cedema ; the legs are swollen from the knees down- 
wards, and the scrotum is (edematous. Liver one inch below 
ribs. Apex beat can be seen and felt one inch external to line 
of nipple and about three inches below it, in sixth space. Pre- 
cordial dulnesB increased. Systole laboured. A presystolic 
bruit is heard at apex and the second sound is reduplicated at 
base. Pulse full, persistent, vessels tortuous, very high 
arterial tension. 



iiy Foud's Bpbj'gmogTiipti. rreMUte not recorded. 

Chest large and barrel sbaped, epigastric angle wide, expan- 
sion mack impaired. Loud and noisy inspiration; expiration 
prolonged and accompanied by r&Iee on both sides. Urine 
rather dark, sp, gr. 1023, no albumen, bile, or sugar. A 
note of the urine was made on May 6th, 12th, 19th, S7th; on 
neither day was albumen present. On May 27th he left the 
hospital, bis bronchitis having cleared up a good deal ; his heart 
sounds remained the same. He was readmitted on June 17th. 
On this occasion be walked into the ward, but the exertion was 

VOL. XXV. 22 c;003lf 



3S8 Chronic Brij/ht's Disease unthoui Albttmimiria. 

too much tot him, aud be became very blue ; his tfaighs, legs, 
feet, and scrotum are now vGr;^ much swollea, the right leg 
meaauriDg eighteen aud a half, the left aereuteeD inches 
round the calf. Apex beats two inches external to nipple, and 
the ares of cardiac dnlnesa is largely increased ; there is a 
presystolic bruit and a reduplicated second sound. Both 
jagolars pulsate, filling from below. Very persistent pulse. 
Tortuous and distended temporals. Urine scanty, loaded with 
lithates, CO albumen. Southey's tubes were subsequently 
introduced into his legs, but he became day by day more 
exhausted by his pulmonary and cardiac dyspnoea and died on 
July Ist. 

Patt-mortem report (by Dr. Fagge). — " Brain healthy. 
Lungs rather oedematous, some small apoplectic patches. 
Heart 23 oa., all the cavities dilated and hypertrophied ; 
aortic valves appear competent, but two were adherent half 
way to their centres aud bad very thick calcified edges ; the 
mitral orifice wide, admitting more than four fingers; the 
edge of the valve seemed to turn in aud there was rippling of 
the posterior wall of the auricle. Liver nntmegged. Stomach 
and intestines congested. Spleen indurated, 5 oz. Kidneys 
indurated, 11^ oz. Their capsules adherent, but I was not 
clear that there was any disease of importance ; their arteria 
(Appeared rather thick." 

Case 7. Hypertrophied and iRlated heart; ten^xtrary 
mitral regmgiiation ; bronehitia i albumen on one oectuum; 
high arterial preantre.—Jme G — , set 57, Dr. Wilks {Clin, 
clerk, Mr. Rowlands). July 16th— October 11th, 1879. 
Family history good. Patient has always worked hard, has 
been much exposed to wet and cold. Is married, has had 
seven children. Has always been healthy up to seven years, 
when she had ulcers on her legs, which troubled her for some 
yeara afterwards. Two months ago she began to suffer from 
constipation and difficulty in passing water, which was scanty 
and high coloured. She has had pain in her left side ami 
stomach, and shortness of breath ; egdema of feet and legi. 
She is a largely made, bloated-looking woman, with pendulous 
choeks, subconjunctival oedema, and the aapect of cardiw 
distress. She has much dyapnoea. Vesicular mormur bn* 



Chronic Briuht't Disease wilKoui Albutninuria. 339 

and coar&e all over cbest ; slight crepitations behind at the 
bases of the luogs. On admission puUe very irregular 
and B systolic bruit audible at the apex. A week later 
I note that " the bruit has disappeared, but the rhythm 
is still irregular ; the second sound is accentuated and the 
apes beats one, to one and a half, inches external to nipple. 
The pulse is very persistent and many beats are long." The 
appetite is bad ; bowels confined. The liver can be felt two 
iacbes or more below the ribs. The urine contained a trace 
of albumen ou the day of admission, but never afterwards. It 
was generally of pale colour and of rather low specific gravity. 
For further details see table. August 3nd. — She is described as 
feeling better, cough less, heart more regular, no bruit. Liver 
still enlarged. Her condition continued much the same till 
the time of her discharge, October Uth, when it ia noted 
tliat the bruit is still audible, and the feet swell at night time 
»heu she has been about all day. 



1012 
1024 
1021 
1018 
1012 
1015 
1022 
1010 
1010 
1012 



1006 
1010 
1010 



1012 
1010 
1010 
1010 
1016 
1016 



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340 Chronic Briffhfa Disease mthaui Albuminuria. 



1010 
101 G 
1012 
1012 
1012 
1015 
1015 
1013 
1016 
1010 
1012 
1012 
lOia 
1010 
1010 
1012 
1012 
1012 
1012 



Cask 8. Hypertrophied and dilated heart ; pretj/iloUc 
bruit? very high arterial pressure; headache; urine Hormal. 
—Sarah B— , let. 49. Dr. Moxon (Clin, clerk, Mr. A. P. 
HilU). Ma; 3rd— Ma; 27th, 1879. Book-keeper and 
manager of a hotel until eighteen months ago ; since then 
she has followed no occupation. Mother died, et. 65, of heurt 
disease. One sister has had acute rheumatism, nhich «u 
fulloved by heart disease. For last tn-eoty-three years hta 
been subject to headaches coming on about noon ; at first 
they only occurred about oace a month, last summer tLef 
became more frequent, occurring once a week, and now ther 
sometimes continue fur three days instead of one. Wben 
S5 years of age she had nhat she calls "rheumatic gout." 
She now complains of constant pain orer the back of the beid 
on the right side; sometimea it spreads all over the head, and is 
so severe that she is afraid of losing her reason. A week 
before admission she had what appears to have been u 
attack of urticaria. She is a well-nourished woman, with 
a tranquil expression ; venules of cheeks, chio, and nose 
dilated. Appetite bad, morning nausea, coustipatioa. Ab- 
dominal viscera appear normal. Respiratory system nornial. 
Cardiac impulse in fifth interspace external .to Bimile. A 



Chronic Srighft Diieate vnthout Albuminuria. 841 

presystolic brnit is stated to have been heard by mjaelf and 
the houBe-phyaician. Radial pulse' 84, large, long, iacom- 
pressible, and regular; n pulse of very high tension. The 



Rj PoDd'a Epbygni^Taph. Prestnre not recorded. 

sphygmographic tracing confirms this description, and shows 
nnusaally high pressure. Sight very weak, cannot read a 
paper, sometimes even witii very strong spectacles. (Uafor- 
tunately the report contains no account of tbe condition of 
her retina.) She passes a large qaaotity of urine ; last summer 
it was as much as five or sis pints a day, no albumen or 
sugar, sp. gr. 1012. Catamenia ceased eight months ago. 
An account of the urine is given in tbe accompanying table. 
Though frequently examined uo albumen was ever discovered 
in it. Treated by the ordinary vrhite mixture her headache 
was relieved, but not cured. 

Dile. Qiulitj. Bp. p. BoUdi. lib. 



1012 
lOIO 
1010 
lOSO 
1014 
1012 



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842 Chronic Sriffhft Disease without Albuminuria. 

Case 9. Dilated heart mth ante-mortem thrombi ; aoflening 
of brain from embolism ; old cerebral heemorrhages ; mixed 
kidneys; albumen variable, sometimes absent; death. — Add 
S— , tet. 48. Dr. HaberBhon (Clia. clerk, Mr. Morse). 
February 24th— March Slst, 1879. Her father is said to 
have had rheumatism, otherwise her family history is good. 
She states that she has had erysipelas five times all over her 
head. Fifteen years ago she 6rBt noticed paio iu her heart aud 
palpitatioD after draggiog heavy weights. Since theo she has 
often had winter cough, which has been especially trouble- 
some these last three winters. She has kept her bed, more or 
less, OQ account of her cough, since last November. On 
admission she sits up in bed, is unable to lie on her back, face 
very bine aud congested, looks very distressed, and has great 
difficulty in breathing. Appetite had. Nausea. Bowels 
confined. Liver enlarged, three inches below ribs. There 
are signs in her chest of considerable bronchitis. Heart's 
impulse diffused, right side enlarged. Both sounds indistinct. 
No bruit. Pulse persistent, small, and long; high arterial 
pressure. Urine sp. gr, 1020, neutral, deficient in quantity, 
a great deal of albumen; no sugar. March 1st.- — About 
9 a.m. she had a kind of fit, but apparently without loss of 
consciousness. At 12.45 it was observed that she had partial 
loss of speech, chiefly ansvfering "Yea" to all questions; 
there was loss of power in right forearm and hand, in right leg, 
and in muscles of right lower half of the face. There was loss 
of sensation all over the right side of the body. Optic discs 
normal, no difference between the two sides, some hyper> 
metropia. The paralysis improved rapidly. March 5th. — 
Urine, sp. gr. 1026, only a trace of albumen. March 8th. — 
Urine contains a trace of albumen, sp. gr. 1023. March 
10th. — Has recovered the use of her arm and leg, and is able 
to express her thoughts better ; no albumen in urine. March 
14tb. — Patient is better; no albumen in urine, March 18th. 
— Patient looks very livid this morning, and her ideas seem 
very confused ; it is supposed that she was seized with another 
fit in the night. She complains of great pain about the 
scrobiculus cordis. Breathing 41 per minute. March 19th. 
— Patient had another attack in the night, and was cupped on 
the shoulder ; 4| oz. of blood were dfawn off, This morning 



Dig t,zec.y Google 



Chronic Brighfs Ditease vnthout Albuminuria. S48 

she looks very bluej reap. 46, pulse 120, temp, normal. 
She spits up a good deal more blood thnn berore the attack. 
March 20th. — Urine dark coloured, sp. gr. 1033, quautit; 
small, albumen about a quarter, no trace of blood. March 
22nd. — Patient looks better. Urine ep. gr. 1025, a small 
qtuDtity of albumen. She still spits dark lirer-coloured 
sputa. She became worse on the 28th, gradually getting 
more blue and exhausted. She died on the Slst. 

Po»t mortem (by Dr. Goodhart). — " Slight dropsy of legs. 
Body fat. Brain 43 oi. The vessels at the hnse were all of 
small calibre and thick, nith patches of atheroma, which 
closed them in fast, so much so that I thought at first that 
the left iuternal carotid was plugged ; it was not so, however, 
the caoHl vas merely contracted, and after careful examiuation 
I could nowhere detect an actual plug in any vessel. The 
vessels under the microscope were decidedly thick. There 
was a large patch of softening affecting the grey matter of the 
couvolutioDS of the left inferior pHrietnl louule, and extending 
irregularly into the white matter also, which occupied a con- 
siderable area behind and external to the central nuclei on 
this side" (the details of this need not be given here). "There 
was one patch of old brown extravasation in the uncinate 
gyrus, and another in the pons. Lungs somewhat decern- 
posed ; there was a large gangrenous cavity in the anterior 
part of the middle lobe, and around it several masses of 
pulmonary apoplexy. (The cavity probably took its origin 
from a similar condition.) Heart 25 oz; right anricular 
appendix full of large cystic ante-mortem coagula, their 
central parts being softened with grumous fluid ; right 
ventricle thick and dilated; left ventricle also thick and 
very dilated, with, at the apex of the left ventricle, a half-incb 
sized mass of ante-mortem coagulum; the mitral a little 
stretched and thick ; aortics also a little thick. The aorta 
bad, just above the two anterior valves, a peculiar linear scar; 
the margins of the scar were sharp, its surface was depressed 
and thin, it tailed away into a point. I think it must have 
been due to some previous slit in the artery and to the healing 
of this. Aorta fairly good. Liver 75 oz., healthy. Spleen 6 
oz., firm. Kidneys 15 oz; surfaces granular with a few 
ysts in them; the organs indurated and muddled. They 

. „Gooj^lc 



34i Chronic Briffhl'a Disease without Albuminuria, 

vere gratiular kidneys, altered in appearaoce by a cerUia 
amount of chronic induration due to cardiac congestion. No 
gout in the great toe-jointB." 

Case 10. Dilated and hypertrophied heart; tiutral reifurgita- 
tion ; perihepatitia ; ascites; high arterial pressure : urine nor- 
mal; death. — Annie U — , tet. 49. Dr. Habershon (Clin, clerk, 
Mr. Thomas), December 28th — May 29th, 1879. Her father 
(lied from apoplexy. Her mother at an advanced age. One 
brother died from dropsy and heart disease. She does home 
vork and has not drunk much. Never remembers being ill till 
five years ago, since then she has had cough and purulent ei- 
pectoratioQ. She has been feeling seriously weak and ill for 
the last year. About four months i^o she noticed that her 
lower eyelids and cheeks began to swell, also her feet and 
ankles j the swelling of the face and eyelida was worse in the 
morning, that of her feet at night. She went uuder treatment 
hut found her abdomen, thighs, and legs getting larger ; the 
increased swelling caused her to apply for admission. Oa 
admission she is a fairly nourished woman. She sits propped 
up iu bed, with a good deal of dyspnoea, face pale, aad 
anxious, great cedema of legs and of trunk, especially in lumbar 
region ; less (edema of arms ; abdomen distended with ascites. 
Lungs resonant, but with prolonged expiration aod sibilant 
rhonchi all over them, except at bases behind, where there are 
mucous r&les. Heart's apex bcatsin fifth interspace, aboutbalf 
an inch externa] to nipple. Area of cardiac dulneas increased. 
Loud systolic bruit at apex. Pulse 44, weak and irregular, 
very compressible. Very little urine passed ; she sometimes 
remains twenty-four hours without passing any. It is rather 
light coloured, sp. gr. 1028, acid reaction, no albumen and no 
sugar. On January 8rd I made the following note : — " Pulse it 
long and persistent though small ; the srtery is not very full, 
but is discoverable during diastole, There is " aafety-vihe 
action of the mitral ; occasionally there is a double heart heat 
to each pulse," January 15tb. — She is atill in the same 
general condition, but her pulse is 88, while her heart is 56 
per minute. She has been taking digitalis four days; this 
is now stopped. January 28th. — Urine ap. gr. 1026, no 
albumen, large deposit of lithates. February Ist.— Pancen- 

. „ Google 



Chronic Brighfs Diaeaie without Aibuminttria. 3-15 

tesis to 10 pts. 6 oz. Much relieved. This nas repeated od 
March Ist. Her condition remained obstioately the same ; her 
nrine, which was measured almost daily, could not be increased 
in qnantity br any form of diuretic employed ; the Mist. Senega, 
Mist. Copaib. Res., and the diuretic pill, were ali employed 
without avail ; urine varied from 12 oz. to 18 oz. in the twenty- 
four hoars. Paracentesis for the third time on April 15l]i. 
She has some severe bed sores. Parncenteeis for the fourth 
time on May 29tli. After this she sank rapidly and died. 

This case closely resembles Cases 11 and 13 in my paper 
on the " Clinical Aspects of Chronic Bright's Disease," its 
characteristic featurea being bronchitis and heart failure, wiih 
capsulitis of the liver and obstinate ascites, all more or less 
directly the outcome of chronic Bright's disease. 

Poat mortem (by Dr. Hilton Fagge). — " Wasted upper part 
of body. Swollen lower limbs. A large quantity of Buid in 
right pleural cavity, compressing lower part of lung, which was 
covered with a honeycombed layer of vascular lymph. Lungs 
somewhat CBdematous, otherwise healthy. A good deal of 
cedema in larynx, especially of left fold, also at base of tongue, 
in left aide of soft palate, &c. Heart 15 oz., dilated rather 
than bypertrophied ; left auricle decidedly hypertrophied 
and crisp ; mitral valve healthy ; aortic valves healthy ; right 
auricular appendix filled with rounded softening thrombus. 
Peritoneum contained much straw- coloured fluid, and was 
generally thickened and slightly contracted ; around the small 
intestine it was black. Liver 44 oz., perihepatitis, with an 
areolated separable layer; the tissue was rather cirrhotic. 
Spleen 8 oz. Kidneys 10 oz. ; their tissue markedly blurred ; 
thickened arteries ; granular on the surface, but no indication 
of fatty epithelial changes. The microscope showed that there 
was extensive change, but I must confess that much of it 
appeared to be of a recent character, consisting of a cellular or 
nuclear infiltration. This was especially tbe case in the 
cortex, just beneath the capsule, where the greater part of the 
tissue was converted into a dense aggregation of nuclei. Also 
in deeper parts, around the Malpigbian bodies, and around 
the vessels, and in some places without any obvious cause, the 
stroma was greatly swollen and infiltrated with nuclei. The 
tnfts also were crowded with nuclei. A few of them'were 



S46 Chronic Bright** Diteau vnthout Albuminuria. 

degenerated and coatracted. The Btroma generally wu, I 
thitik, decidedly thickeoed and more fibrous than usual, in 
some places very much so." 



II. Cases of Lcnq Failure. 

Case 11. Acitie upon chronic bronchitis ; hypertn^hied a«d 

dilated /teart ; large granular kidneys, with acute epithelial 

changes, producii^ albuminuria thirteen dags b^ore death; 

urine previauslg normal ; thick arteries ; high arterial pressure ; 

rfe«/A.— William W— , mt. 48. Dr. Haherahon (Clin, derk, 

M. Gilkes). April 18th— May 16th, 1879. His father died 

a youDg man, be believes from consumption ; bis mother had a 

joint affection which produced deformity of the joints affected ; 

other family history uuimportant. He vas a carman f>ir 

thirteen years, and after that a general labourer. He has 

been very subject to carbuncles, giving an account of seven 

of which lie bears the scars. He says that he has been the 

subject of asihmR, which in the winter of 1877 turned to 

bronchitis ; he was in Stephen Ward under the care of Dr. 

Wilks. He then suffered from symptoms closely resemblio^ 

those for which he is now admitted, and his ariue was free 

from albumen. Has been a moderate drinker, and smokes 

about half an ounce of tobacco a day. He was laid up with 

the present illness five weeks after Christmas, since which 

time hia cough has varied in severity, sometimes allowiug him 

to work for a week or two. He is of average height. He is 

intensely cyanosed and has much dyspnma. Sweats freely- 

Nails clubbed, fingers thick. Subconjunctival oedema. He 

brings up frothy muco-pumlent secretioa. 

over front of chest, dnloess at sides and 

ind sonorous rhonchus heard over front, 

back of chest. Heart's dulness increased, 

nch beyond nipple, and for about four inches 

) the left of sternum ; no bruits. " Pulse 

>ng, and extremely high pressure." Urine 

coloured, loaded with lithates, oo albumen. 

al. April 22nd.— Urine sp. gr. 1030, loaded 

albumen. He still continues very livid; 



, GoeK^Ic 



Chronic Bright't Disease toithout Albuminuria. 347 

respirations only SO; he is rather drowsy by dny, restless at 
night. April 24tb. — Expectorating bright blood, which on 
the next two days is rusty. April S6th. — I have a note as 
foUows : — " Pulse still persistent bat feels much tkorter^ he is 
not so irell. His first sound appears to roe like a presystolic 
brait, such as I have heard occasionally in dilated hearts." 
April 28th. — Less blood in sputa ; patient more cyanosed ; feels 
better in the early morning, bnt has had another faint attack, 
which has lasted more or less all day. His pulse is very 
irregular and sooietiroes intermits. Expires very freely. 
Mucous i&les all over back of chest, sibilant rhonchi in front. 
April 30th. — Urine small in quantity and loaded with lithates. 
May 3rd. — Patient feels weaker; his abdomen is filling out, is 
dull on percussion, pendulous, and Suctuation can be felt. 
Urine sp. gr, 1030, albumen jth. May 6. — Respirations 32, 
temp. 96-8°. Urine sp. gr. 1034, has passed 18 oz. in last 
twenty-four hours, Hcid lenction, loaded with lithates, albumen 
^th. Feels weaker ; conjunctiva congested and cedematous. He 
steadily became worse ; abdomen distended, legs cedematous, 
pulse too feeble to feel at wrist. Urine remained scanty and 
albuminous. 

Post mortem (by Dr. Hilton Pagge). — "A large bulky man, 
with much dropsy of leg^. Biaiu 56 oz., iiealthy, small arteries 
free from thickening. Lungs extremely emphysematous, espe- 
cially the ear-shaped process of the left lung, which formed n 
large bladdery appendage connected with the lung by a narrow 
pedicle. There was a good deal of oedema. Bronchia velvety 
and full of pus, not generally dilated, although I found one 
tube in the right base which was so. Heart 20 oz.; muscle 
of left side soft and pale, of right firm, red, and indurated ; a 
little atheroma on mitral valve, otherwise healthy; aortiti 
valves liealtfay. Pulmonary artery as thick as aorta. Stomach 
iutensely reddened (by mode of death). Liver congested in 
hepatic area. Spleen 8 oz., indurated, Kidneys 15 oz., deeply 
congested, but with very marked normal structure; their 
lurface smootli and capsules thiu. However, the microscope 
showed that they were far from being in a normal condition. 
I only found one Malpighian tuft degenerated, but the stroma 
was much increased, and in some parts the tubular structure 
seemed to be lost. In a pencilled preparation there was a, 

, Gooj^lf 



848 Chronic Bright'a Disease without Albuminuria. 

continuous plane of fibrillated material, dotted with fat granules 
and nuclei. The tubes were choked with granular rantter. 
No doubt the epithelial changes nere recent, coinciding nith 
the congestive albuminuria, but I think there was olcter 
interstitial mischief." 

Case 13. Pleuritic effusion ; pulmonary apople^'y ; dilated 
and liypertrophied heart ; granular kidneys ; high arterial 
pressure; urine normal; death. — Helen E — . set. 52. Dr. 
Pavy (Clin, clerk, Mr, Crosse). March 9th ; died March 
23rd, 1880. An Irishwoman. Has lived in Loudon since 
she was thirteen years of age. Married twice. She worked 
in white lead for ten years ; she ceased to work in it five 
years ago. She once had a blue line on her gums. Good 
health till twelve months ago, when she began to suffer bom 
cough ; occasionally had heemoptysis. Last November attended 
as an out-patient with very severe cough ; she spat blood at 
this time. On admission she is a thiu, emaciated woman, 
looking ten years more than her age. She has great dyspnoa, 
and is expectorating dark, thick, tenacious, blood-stained, and 
frothy sputa. Heart's action frequent, sounds slapping. 
Pulse " frequent, small, long, and hard." General signs of 
bronchitis in the lungs. 

March 12. — Urine sp. gr, 1020, no albamen, lithate*. 
March 16th. — Urine sp. gr. 1016, no albumen, no lithatei. 
Patient continues in much the same condition as on admisaion. 
Urgent dyspnoea. Great debility and exfaauatton. No sleep. 
Takes bnt little food. On March igtfa it is noted thai the 
pulse is intermittent, dropping every fouth beat. Appears to 
be sinking. She is too ill to permit much examination. 
March 22nd. — Pulse very irregular, but much stronger. She 
wanders and is half unconscious. She died the following day- 

Post-mortem examination (by myself). — "Emaciated. Slight 
osdema of legs. Right pleural cavity contained a layer of 
gelatinous material and sernm, and was lined with corpuscular 
lymph. Left contained a considerable quantity of clear semni, 
but no signs of inflammation. Bight lung ; cicatrical noddle 
at apex, with slight emphysema over it ; at base the inng 
was so much compressed by fluid in pleura as to sink in 
water. Left lung : two ante-mortem thrombi were found in 



Chronic RrigAt'i Disease untAoUl Albuminuria. 849 

branches of the pulmonary artery the sise of a No. 4 catheter. 
Que was appareatly recent and there was no infarct in the 
lang. The other was of older date and more firmly adherent 
to the wall. There was a la^^ iiifarct in the area of lung 
supplied by this vessel; this was situated at the base of the 
lung. The lungs were both csdematoaa, especially the left ; 
'both were indnraied and shrunken looking. Bronchi and 
Teasels thick and prominent. The tubes at the base of the 
right lung, in the collapsed portion, exuded pus freely. 
Heart 16^ oz., enlarged, pale, and flabby looking ; both 
Tentricles equally enlarged ; muscle pale, but not softened ; 
leli auricle considerably dilated; left ventricles dilated and 
thickened. The endocardium was thickened. The chordee 
much thickened, greatly shortened, and matted together ; the 
valve flaps were much thickened. The mitral orifice admitted 
only the tips of two fingers, it was distinctly stenosed. Aortic 
valves white and thick, otherwise healthy. Right ventricle 
and auricle a little dilated. Pulmonary artery nhite and 
thick. Aorta ratbei- thick and inelastic, but no atheroma. 
Arteries generally very greatly thickened. Liver Ai oz., pale, 
friable, with a good deal of mottling from hepatic congestion, 
a rather atrophied-luokiog organ. Spleen 8 oz., small, firm, 
indurated, with thick arteries. Kidneys 5 oz., both of tliem 
typical specimeus of true granular kidney ; they were small 
highly granular organs, the granulation being perfectly even 
and regular throughout ; the capsules somewhat adherent ; 
the cortex very greatly wasted, reduced to one eighth of au 
iucb. They were of an even red colour, there was no yellow 
mottling; no pallor of the cortex or hypereemia of the pyra- 
mids. The arteries were very greatly thickened ; the coats of 
the renal artery looked twice their normal thickness. Pelvis not 
dilated ; ureters normal. In the cortex of one kidney was a 
small patch of atrophy following an old infarct, of which there 
were still some remains. No signs of gout in toe-joints. No 
external deformity of any joints." 

Casb 13. Bronchitis; (edema of lover exiremities ; jaun- 
dice ; gall-atones ; Ayperlrophied heart ; granular kidneys ; 
urine at first normal, afterwards a trace of albumen ; death. — 
William G— , let. 43. Dr. Pavy (Clin, clerk, Mr. Bryden}. 



350 Chronic Bright's Disease loHkout Albuminuria. 

Admitted Mnrch 27th, 1878; died Juue IStli, 1878. 
Family history good. He is ;i clerk, iias aiuays been f«irly 
healthy. He has beeu aflcctud since boyhood witli an augulur 
ciinrature of the spiue. Six iveeks ago he was ojierated on for 
piles. No history of syphilis. He has di-uuk hard. Since 
his operation he has suft'ured from weakness, shortness of 
breath, and cough. He is a rather delicate, somewhat 
emaciated man, with a mild expression and slight tiuge of 
redness on the clieeks, altliougU he is geiierally anemic. He 
presents the ordinary symptotus of bronchitis. Caidiac impulse 
jerky and diffused ; the area o£ duhiess may be slightly 
increased ; the sounds appear muffled, the secoud is not clear. 
Radial puise is somewhat frequent, hard, and regular. Urine 
Jiglit straw colour, sp. gr. 1015. No albumen or sugar, 

normal in quantity, phosphates are present. April 8rd. 

There is duJness at left apex, deficient movement, and deficient 
entry of air. April 8ih.— Legs began to swell yesterday 

evening, and are rather cedeuiatous now. April 18th. Urine 

Bp. gr. 1015, some albumen present. April 23rd. — Lower 
extremities ^nd scrotum much swolleu. He has much diflS- 
culty in breathing. April 24th. — Jaundice first observed. 
April 26th. — Urine contains bile and a trace of albumen. 
May 6th. — The jaundice has passed away. The cedema of 
lower extremities, external genitals, and wall of abdomen per- 
sisted, his breathing became more difficult, and he died 
exhausted on June 15th. 

Post mortem (by Dr. Fagge). — "The body was that of a 
heavy man with an angular curvatare in the dorsal region. 
The lower limbs were very cedematous. The lungs contained 
much fluid. Heart 17 oz. ; one of the aortic valves had a vege- 
tation of considerable size upon it. Liver 61 oz., flattened in 
shape, with a transverse groove, probably caused by the dis- 
torted ribs. The ducts throughout the liver appeared slightly 
wider and more conspicuous ou the cut surface than usual. I 
think the common duct was also widened, but the orifice into 
the duodenum was of natural size. In the common duct lay 
an angular black gall-stone ; there were no others in the gall- 
bladder. Spleen 9 oz. Kidneys much wasted and very 
granular, one much smaller than the other." 

Dig zee. y Google 



Chronic Bright't Dueaae without Albuminuria. 351 

Case 14. Bronchitis; kypertrophied heart ; granular kidneyt ; 
high arterial pressure; urine normal; death. — George T — , 
St. 46. Dr. Wilks. November 22nd; died December 6th, 
1879. Two mouths ago he complaioed of cold, pains in back, 
knees, &c. He had cough aod dyspocca^ which caused him to 
apply to the hospital. Od admission he hud a congested face, 
a hard pulse, no dropsy, laboured respiration, course ifiles all 
over cheat. Uriue pale yellow, no albumen. Before death he 
was delirious, with very hard breathiug, which stopped sud- 
denly. 

Post mortem (by Dr. Fagge). — "Body not nasted. Brain 
healthy. Chest contained three or four quarts of fluid. 
Lungs rather emphysematous. The larger tubes contained 
pus and the lung tisaue was in places cedematous. Larynx 
healthy. Heart 25 oz. ; left ventricle appeared not dilated. 
Liver 64 oz,, uutmegged. Spleen 7 oz., very hard and fleshy. 
Stomach intensely congested. Kidneys 8 oz., very granular. 
Hasted, red, with thick arteries. No gout in great toe-joiuts 
or knees." 

Case 15. Bronchitis; dilated and hypertrophied heart; 
renal dropsy ,- uriw usually normal, but allmminous on three 
occasions. — Samuel D — , set. 56. Dr. Fye-Smith (Clin, 
clerk, W. Spong). December IBth, 1879— March 24th, 1880. 
A labourer in Woolwich Arsenal. Family history good. He 
had rheumatic fever thirty years ago ; temperate. He 
attended as an out-patient during January, 1879, with cough 
and expectoration. About three weeks before admission he 
noticed that he was short of breath on going upstaire ; he left 
off work a week later (December 4th), when his legs had com- 
menced to swell. On December 8th he noticed that his face 
was pufiy and swollen especially under the lower eyelid ; this 
lasted for three or four days, and then gradually subsided; 
meantime his legs continued to swell and bis abdomen became 
enlarged. On admission he is described as antemic, with 
blueness of lips and a distressed expression. He is sitting up 
in bed gaspiug for breath, but has no cough. There is 
marked Gubconjunctival oedema. Skin dry and harsh. There 
is more or less anasarca all over the body, especially in legs, 
thighs, and abdomen : peois and scrotum slightly CBdenutous. , 



352 Chronic Bright't Disease without Albuminuria, 

There appears to be little or uo asciteS] though the abdomen 
is distended aad tease, so that the umbilicus appears as a 
transTcrse slit. Liver eolarged, its lower edge can be felt 
about one inch above the umbilicus. Chest resooaiit except 
at bases behind, which are both dull. Expiration prolonged, 
breathing harsh, with r&les at the bases. Cardiac dulness 
increased ; apex beat oae inch below and half an inch to outer 
side of nipple. (There appears to have been some doubt about 
this, as a marginal note says " Impulse feeble, not displaced ; " 
on the other hand, it is later on again reported as much dis- 
placed). Heart sounds very indistinct and feeble, no bruit 
audible ; sounds heard beat at ensiform cartilage. Pulse 
small, weak, regular, and compressible. On December 24tb. — 
I have myself noted, "Fulse small, but long and very incom- 
pressible, the harder you press the plainer it becomes." For 
four or five days before admission he is said to have passed 
very little uriue. On admission it was dark coloured, loaded 
with lithates, sp. gr. 1016, slight trace of albumen. Decem- 
ber 18tb. —Urine sp. gr. 1012, clear amber coloured, contains 
uo albumen, sugar or blood. Microscopical examination. — No 
casts can be seen, no blood-corpuscles, abundance of epithelium. 
By December 22ad much improvement bad taken place. The 
oedema was much less, his urine having been steadily iucieasing 
in quantity. His leg, round the knee, measured 13 inches 
DOW, against 16 inches at time of admission. Heart sounds 
more distinct. Lungs as before; still dull at bases. Decem- 
ber 29ih. — Feet and legs only slightly oedematous. On 
January 13lh lie left the hospital for awhile, very much 
improved ; the lungs hud completely cleared up, though the 
respiratory murmur remained harsh. The urine had never 
been albuminous since the day after admission. 

He was readmitted on February 24th. His conditioa is 
very much worse. His breathing is very difficult; he cannot 
lie down at night and he gets but litttle sleep ; his cough is 
troublesome, with scanty, thick, bronchitic sputa. He has 
■ubconjunctival oedema, rather pufiy lower eyelid, and dropsy 
of legs and feet. No oedema of scrotum or abdomen. Heart's 
impulse 2\ inches below left nipple, and IJ external to it. 
Heart sounds muffled and indistinct actios — " cantering ; " 
first is very markedly reduplicated, and second is aocflntnated. 

. , Google 



Chronic Bright's DUeate without Albumijoiria. 



353 



Pulse small and easil; compressible. Lung eounda mucli as 
on previoQB occasion, but now there was thongfat to be slight 
dulness at rig^ht apex. Urine normal in quantity, amber 
coloured, acidj sp. gr. 1020, and contains no albumen. 
Febmary 28th. — Yesterday afternoon patient had a very 
severe attack of dyspnoea, so bad that he appeared in danger 
for his life. The bowels had been very confined. He was 
dry capped in twelre places, and fui elaterium powder ordered, 
ubich purged his bowels thirteen times. This morning he is 
considerably better. His long sounds are the same, the 
bsaea behind being deficient in resonance; rhoncbus beard 
with inspiration and r&les with expiration. TTrine ep. gr. 
1024, no albumen. Pulse feeble and regular, B6 per minute. 
March 4th. — Patient still complains of haTiug to get out of 
bed at night because be cannot breathe. The following day 
cedema of the penis is noted ; three days later this bad dis- 
appeared, March 12th. — He is up and feels better. His con- 
dition steadily improved and be went out on March 24tb. 
An account of his urine is appended j it was only albuminous 
on three occasions, onoe on first admission, and twice afler- 
vards. 



Dec. 16 . 


Mot. 


1016 . 


800 


. Slight tnie. 


17 


. 32 „ 


1012 


8S4 


None. 


J8 . 


. « „ 


1012 . 


662 


. 


19 . 


. 60 „ 


1014 


810 


.. 


£0 


60 „ 


1012 


720 






21 . 


- 72 „ 


. 1012 . 


864 






2S 


70 „ 


.. 1012 


SW 






2S 


. 70,. 


.. 1018 , - 


. 910 






34 . 


60 „ 


1014 


700 






S5 . 


. 52 „ 


1014 


728 






26 . 


. 60 „ 


1012 


720 






27 . 


■ 72 „ 


lOlB 


1080 






28 . 


. 72 „ 


.. 1016 . 


. 1080 


„ 




29 . 


■ 64 „ 


.. 1016 


. 1024 






30 


34 „ 


1015 


610 






31 


■ 82 „ 


1016 . 


. 512 


,. 




J.D. 1 . 


32 ,. 


1018 . 


676 






2 


■ 28 ,. 


.. 1016 . 


443 






3 


. 30 „ 


1018 . 


640 






4 


22 „ 


1016 


330 






VOL. ixv. 








a 


3 r 



Gooj^lf 



354 Chrome Brigkt't Dueaat mtkout AOtonimtria. 



Jan. fi ... ae ot. ... lOlB ... 46& ... Nooe. 

6 ... SO „ ... lOao ... 80O ... 

7 ... 26 „ ... lOiO ... MO ... 

8 ... !S . ... loss ... 4S1 ... 

9 ... 29 ,. ... lOM ... 660 ... 

10 ... aa . ... 1025 ... 800 ... 

PdIt. BUterii SaL, rt. xii. 

11 PuTBtd fr«el7 and tnoefa relieved. 

12 ... 32 oi. ... 102B ... 800 ... 

13 ... W» ... 1026 ... 800 ... 

14 ... 46 „ ... lOIS ... 1160 ... 

Wentont. 

Feb. 86 ... 46 „ ... 1020 ... 920 

28 ... 46 . ... 1021 ... 966 ... 
27 ... 40 a ... 1020 ... 800 ... 

2S ... 80 „ ... 1084 ... 720 

29 ... 28 „ ... 1026 ... 728 ... A tnee. 
Mu. 1 ... 80 „ ... 1022 ... 660 ... • 

2 ... 36 . ... 102* ... 864 ... None. 
8 ... 86 „ ... 1020 ... 700 ... 

4 ... 84 1024 ... 816 ... 

Unct Digital., nx i VJ^k- Senega, 3j, ter die ; followed by gnat 
impTOTement. 

5 ... 40 OI. ... 1016 ... 640 ... Kone. 

6 ... 88 „ ... 1020 ... 660 

7 ... 60 „ ... 1015 ... 900 ... 

8 ... 60 1012 ... 720 ,„ 

9 ... 80 „ ... 1014 ... 1120 ... „ 

10 ... 86 1018 ... 1548 ... 

11 ... 60 „ ... 1014 .. 840 ... 

Cabs 16, Chronic bronehitU : hypertrophied heart; ^^ 
arterial pretture ; urine normal. — Catherine B — , wt. 38. 
Dr. WilkB (Clin, clerk, Mr. W. Spong), January 7th, 1880- 
February 26th, 1880. Haa always bad good health till foor 
years ago, irhen ahe had rheumatic fever; nerer bo well sinK, 
sobject to occasioDal rheamatic pains and to congbs. F« the 
last twelve montba she has been more or leas anwell; ^ 
heart has been irregular, sometimes "dropping a beat," aw 
rendering ber short of breath. For four weeks past she hu 
had pun in lower part of her hack over lumbar re^on. f"' 
the last two months she has lost flesh considerably. 

She is a delicate, anemic, pasty-looking woman. I"^ 
eyelids pufiy and slightly oedematoiu. There are weU-mu^ 



Dig lized^y Google 



tkronie Srighi'a Disease without Albwninttria. 85S 

signs of bronchitis in her chest. Rhonclii heard all over and 
moist sounds abundant at the bases; resonance impaired at 
the bases behind. The heart's apex is much displaced, apex 
beat most distinct 1^ inches below and 1 inch to outer side 
of nipple. No bmit. Second sound very much accentuated ; 
best heard at base and towards the right side. Pulse long, 
T^;nlar, and incompressible. 



Her appetite is bad, and she frequently suffers from nausea 
and sometimes vomiting. Bowels usually constipated. She 
suffers much from headache, which appears to depend a good 
deal on her constipation. She is unable to hold her water 
more than two hours at a time, and is obliged to get np at 
night; she has noticed this since her last confinement. Her 
urine wss perfectly normal during the time she remained in 
hospital. A chart of it is appended. Her cough improved, 
bat nerer completely disappeared. She continued to be much 
troubled by headache. No cardiac bruit was ever discovered, 
but the second sound is always described as very much accen- 
tnated. 



86 „ .. 


.. 1020 


86 „ . 


.. 1020 


B6„ . 


1015 


40 „ . 


.. 1080 


*o„ .. 


1016 


— 


.. 1018 


M„ . 


.. 1080 


82 „ . 


.. 1016 


»„ . 


1018 


as „ . 


.. 1018 


40 „ . 


.. lOia 


80 „ . 


.. loao 


80„ . 


,. 1022 


30„ . 


.. 1020 


58 „ . 


.. loao 



rGooj^lf 



Chronic Bright'x Diteaae toilAout AUmminaria. 



lois 
1018 
lOJB 
1016 
1016 
lOSO 



102fi 
1016 
1016 
lOEO 
1020 
1018 
1016 
1016 
lOlS 



Case 1 7. Chronic bronekitis and emphysema ; ht/pertrophied 
heart ; thickened and degenerate vestels ; high arterial presntre ; 
urine normal.— Owen M— , let. 70. Dr. WUks (Clin, clerk, 
Mr. W. SpoDg). December Slat, 1879— January 28rd, 1880. 
Laboarer in foreign grain warebouBe. Has drank freely. 
Has been snbject to cougli for thirty years or more. For last 
tvo years it baa been more severe and he baa nerer lost it. 
For last twelve months has lost veight considerably. Has 
some difiBcalty of breathing. Sputum muco -purulent and 
abundant. Movementa of chest impaired ; respiration chiefly 
abdominal. Chest resonant all over. Rhonchi during boUi 
inspiration and expiration all over chest. Cardiac dalness 
diminished. Apex of heart much displaced, easily to be felt 
abont 2 inches below and IJ inches to outer side of nipple. 
Heart regular, both sounds distinct, especially the second. No 
bruit to be heard. Pulse regular, hard, and incompreasible ; 
artery thickened and never quite empties itself, easily felt 
under the finger during diastole. Liver displaced downwards. 
He went out relieved of his bronchitis. His urine was never 
slbmninons. 



oy Google 



Chronic Bright't Disease without Albuminurta. 357 



1030 


1000 


loao . 


. low 


— 


— 


1012 . 


480 


1030 . 


920 


loie 


676 


1015 . 


670 


1012 . 


600 


1020 . 


600 


1020 . 


930 


1018 . 


G« 


1016 .. 


480 


1014 


632 



Case 18. Bronchitis; kypertropkied heart; high arterial 
preisure; arine nortna/.-~Thomas F — , get. 66, Dr. Pye-Smith 
(Clin, clerk, Mr. Hind). December Slst^ lb79 — February 38th, 
1880. Admitted for an exacerbatioa of chronic bronchitis, 
from which he has suffered for ten yeara. He has a good 
deal of inspiratory dyspnoea, with much muco-purulent expec- 
toration. RhoDchi and moist r&les in chest. Temperature 
normal. Heart's impulse difficult to feel, displaced about 2 
inches below and \ inch to outer side o£ nipple. Pulse 
extremely long and persistent, occasionally intermittent. 
There was no oedema. Hia urine, was normal in every 
respect during the whole time he was in the hospital. The 
urine chart appended is probably only approximately correct ; 
the qaantity of urine passed can only be taken as a minimum 
amount ; a large amount was probably lost on several occasions. 



1016 
1016 
1017 
1017 
1015 
1016 
1016 
lOlG 
lOlS 
1015 



.„Gooj^lf 



Cknme Brighfa DUeaie wUhont Attumimiria. 



Item. , 


. 1017 


ac , . 


. lOiO 


as . . 


. 1016 


26» . 


. 1016 


40 , . 


. 1016 


46. . 


. 1020 


60 „ . 


. 1017 


«> . 


lOSO 


28 ., . 


. 1020 


SSk . 


1020 


B6 „ . 


. lOlB 


sa „ . 


. 1016 


ss„ 


1020 


M„ . 


1020 


3S. . 


. 1020 


M- - 


. 1016 


60 „ . 


. 1015 


46 „ . 


. lOlB 


« , . 


. low 


40. ■ 


1017 


88„ . 


. 1017 


S8 . . 


1016 


40. . 


1016 


46„ . 


. 1016 


— 


— 






S8 „ . 


. 1016 


40„ ■ 


1020 


68 » - 


. 1020 


36. . 


1020 


as. . 


. 1020 


SO, . 


lOBO 


26. . 


1020 


80 .' . 


. 1020 


&2„ . 


loao 


26 „ . 


1080 


8B„ . 


. 1020 


SS „ . 


. loao 



Cabe 19. — Bronchiiit ; emphy$ema ; high arterial prtmrti 
hat previoualy had albuvdnaria ,- on preaent occaiiim urae 
normal. — John H — , nt. 42. Dr. Pavy (Clin, clerk, Mr. A. 
Perkins). December 10th, 1879— January 10th, 1880. A 
Iftijonrer, Hia raotfaep died, ajt, 72, of ebroQic tttoncbiti'i 

Dig t,zec.y Google 



Chronic Brighfi Dueaae without Albumiavria. S59 

He dates the bTODctiitii, for which he was admitted, from a 
severe illness in 1872, when he says he " took a cold," which 
laid him up for several weeks ; he has been subject to broD> 
chitis ever since. In January, 1879, be was in Clinical ward 
under Dr. Fav;, for bronchitis and emphysema. His urine 
was then loaded with albumen, high coloured, sp. gr. 1030. 
On the present occasion he is admitted with the ordinary 
symptoms of rather severe bronchitis. His aspect is highly 
characteristic of chronic Brigfafs disease. He has a somewhat 
pasty appearance, well-marked Bahconjunctival cedema, and a 
puffy lower eyelid, and flabby, pendulous cheeka. He baa an 
emphysematous chest, and a good deal of bronchitis. Liver 
displaced downwards by lung. Heart's apex and dulneas also 
obscured by lungs. False very persistent, long, but easily 
compressed. It feels like a pnlse of high preisure. His urine 
was neyer albaminoag during his stay in hospital on this 
occasion, nor did it contain sugar ; its quantity was excesuve. 

Dite. Qiualitj. Bf.p. SsUda. Alb. 

Dec 29 ... 68 u. ... 102S ... 1650 ... Nooe. 

30 ... 60 1026 ... 1600 

31 ... 66 „ ... lOaO ... 1120 

J»n.l ... 70 „ .. 1020 ... 1400 ... 

2 ... 76 „ ... 1020 ... 16S0 

a ... 68 „ ... 1015 ... 1020 ... 

4 ... 74 „ ... 1018 ... 1338 

6 ... 70 „ ... 1018 ... 1270 ... 

6 ... 82 „ ... 1018 ... 1476 ... 

■7 ... 80 lOlS ... laOO 

8 ... 100 1016 ... 1600 ... 

9 ... 90 „ ... 1016 ... 1360 

10 ... 86 » ... lOlS ... 1290 ... 

Case 20. — Bronehitit ; gangrene of lung and of toes from 
embolism ; dilated heart, with ante-mortem thrombi ,- enteritis ; 
peritonitis ; kidneys, slight interstitial change ; thick arteries ; 
urine normal; death. — Maurice O'C — , set. 50. Dr. Pavy 
(Clin, clerk, Mr. Anderson). March 30th, 1679; died April 
let, 1879. A carmaa. Family history unknown. He had 
erysipelas two and a half years ago, following a kick from a 
horse. A year ago he was ill for four days, when he had 
great difficulty of breatb'ng find ft cough ; otb^rwiH b^altti 

. „Gooj^lc 



360 Chrome Br^ht'a Diteate without Albummuria, 

hfiB been good. His present illneas commeDced suddeDly, two 
moQtha ago, with a cold aweat and feeling of great weakoess; 
no sbivering. He had a good deal of cough, the sputa being 
frothy and white. For last fortnight he has been worse, the 
sputa being blood stained ; ha has felt very weak and ill lately, 
and has had uo rest at night, on account of his cough. He 
is a pale, thin-looking man ; he is compelled to sit up in bed, 
breathes rapidly and with difficulty, expectorating a quantity 
of blood-stained mucus streaked here and there with pnmlent 
material. Hia severe illness prevents a very complete exami- 
nation of his cbest, but it appears to be resonant all over ; the 
breathing is described by the clerk as " bronchial " all over the 
chest, probably be means " bronchitic ;" in other words, coarse, 
and with slight rhonchus ; moist r&lea are also heard, more 
especially at extreme right base. The heart appears to be 
dilated, action quick and tumultuous ; six or seven beats rapidly 
succeed each other, followed by a pause, and then more rapid 
beats. Something very like a presystolic bruit is heard at spes, 
and the second sound is rough, prolonged, and accentuated ; the 
heart sounds are much obscured by the breathing. I make a 
note that " he has a persistent pulse with thick vessels ; there 
is a sound very like a presystolic murmur, but I do not think 
quite like it. I fancy it is a reduplicated first sound. Chronic 
Bright's disease, with dilated heart from high pressure." His 
urine contains a quantity of lithates, sp. gr. 1030, no albu- 
men. Mental faculties clear. Temperature 99-%°. Mareh 
21st. — " Dr. Pavy saw patient to-day, and detected a short 
presystolic bruit and fiue moist r&)es at base of right luug." 
Heart still very tumultuous, and breathing difficult. He was 
treated chiefly by digitalis, and appeared to improve daily until 
April Ist, when he was found to be much worse, pulse very 
irregular, and breathing hurried. Death occurred that even- 
ing. Unfortunately no Further note occurs in the report 
about the urine after the first day. 

Post mortem (by Dr. Hilton Fagge), — "All the right toes 
are gangrenous and horribly fetid. Lungs bulky and very 
oedematous, but they were also affected by extensive, scattered, 
ill-defined gangrene. The most definite patch was at tlie 
right apex, where there was a considerable cavity, with a 
slongb hanging suspended from a single point. But in most 



DigtizedoyGOOglf 



Chronic Bright'* Ditetue without Albuminuria. 361 

places the gHDgrenous parts were continuous irith those which 
were not so, aod were indicated chiefly fay their colour and 
the dirty green brown fluid which freely exuded, unlike the 
clear serum which oozed from the rest of the lung. (It 
appeared to be just the sort of aSection which would arise 
from socking in of vomited matters, but I could not learn 
that vomiting had been present). Heart 17 oz., dilated 
rather thau bypertrophied, its tissue soft and rather yellow. 
In the apex of the ventricle were several white ante-mortem 
thrombi of various sizes eotaDgled in the mosculi papUlares or 
free in the cavity. Valves healthy. The poplite^ artery was 
dissected out, but hardly low enough; uear its bifurcation 
it contained a firm piece of clot, which I thought to he the 
upper end of an embolus. There was general acute peritonitis, 
the iatestiaes being matted together with recent lymph. The 
lower part of the small iDtestine was firmly wedged into the 
pelvis i the greater part of it was of an intense purple 
colour, and covered with lymph. After removal, the whole 
thickness of the gut was found to be in a most intensely 
inflamed condition. The mucous membrane was of an ashy- 
grey colour, rough, and dry looking. There were two patches 
of this affection, each occupying a foot or two of the length of 
the bowel ; the lower one included the cecnm, the upper one 
was three or four feet higher up. Evidently this enteritis 
(" diphtheritic " in character] was the cause of the acute 
peritonitis. The appendix cteci contained pus, but was not 
swollen or reddened. Liver 6^ oz., fatty, and also rather 
granular on section, probably a little cirrhotic. Spleen, 5 
oz., firm, contained an infarct. Kidneys, 13 oz,, contained 
several infarcts; they were rather flabby organs, but showed 
a good structure iu their cortex; the arteries were rather 
thick and qidll-like. A. microscopical section made by Dr. 
Mahomed was thought to show some intertubular thickening, 
but it seemed to me that this was very doubtful." 
My notes about the kidney are as follows : 
" Chronic tubal nephritis (?), tubes full of epithelium. 
Capsules but little thickened. Arteries much thickened, but 
little intertubular change." A microscopic section accompanies 
this paper. I may here remark that all my notes as given 
here arc made without any knowledge of the kidney or case 

. „Gooj^lf 



362 Chnmie Brighft DUeose without AiAtamnuria. 

from wKicK the wctioii has been taken. I have been c&refiil 
to worit uij material by numbers, and so mix the cases over 
long periods that I can only identify them after reference fay 
means of the number. The obserrationB are therefore entirely 
nnprejodioed. On a second examinatioa I find that I ha?e 
not done justice to the really large amount of intertnbalar 
change present in this section. 

Cask 21. PUAma ; gout ; general aiheroma ; very gramdar 
tidneyt ; heart onlg 11 oz. ; itrine normal ; death. Robert 
C — , St. 65. Dr. Goodhart (Clin, clerk, Mr. A. P. HiUs). 
March 5th; died April 4th, 1879. A warehooseman, but 
has never done any heavy work. His father died of chronic 
bronehitia at seventy-nine, his mother at rixty-nine, cause 
unknown. He has Icet three brothers, of whom two are said 
to have died of " decline," aged seventy-two and thirty<four 
respeetiTely. He is a temperate man. In 1876 he was in 
Guy's under the care of Dr. Pavy with rather severe bronchitis, 
which affected the right lung most ; on this aide there was 
some consolidation ; bronchial breathing and bronchophony 
were heard at right apex, and some dulness and cr^tationa 
at right base behind ; elsewhere in chest the ordinary signs of 
bronchitis. Bis urine then was 1033 sp. gr. and ftee &om 
albnmen. He continned well after this till the middle of 
1878, when he again fell ill with cough ; getting weaker, he 
detennined to ftpply tor admission. He hes mostly on hia 
back, looks depremedj weak and ilL Dilated veasels on 
cheeks. Ho osdema. Some signs of phthisis at both apices, 
especially left. Cardiac impulse acarcely perceptible; dtduesa 
normal ; sounds normal, rather feeble, Folae 84, ndial 
arteries very irr^olar, hard, and beaded. 



n«Miii«3ox. 

He had two attacks of paralysis ; the first, six years aga> 
was confined to right arm, the second was last summer, affect- 
ing the same limb and lasting only a very short time ; it had 
pamed ^ff entirely in two qf three days, Urine 1016, dq 



oy Google 



Chronic Brighft Diieaie wilhout Albuminuria. 363 

slbomeD, sugar, or blood. March 20th and 26th, — No albu> 
mcD in urine. He died on April 4<th. 

Pott morlem (by Dr. Hilton Fagge). — " Sody spare. Brain 
healthy. Recent pleurisy on left side. Lungs affected with 
a markedly tubercalar form of phthisis ; scarcely any tendency 
to caseate. The tubercles in clusters, chiefly in the upper 
lobes. Larynx healthy. Bronchial glands enormously 
swollen, blacldsh grey, firm, and hard. Liver 72 oz., very 
fatty. Heart 11 oz., not hyp^rophied; aorta affected with 
a moderate degree of arteritis deformans. Kidneys 9 oz., 
very granular, with many cysts, and a very wasted cortex. 
Gout in toes. Intestine presented numerous tubercular ulcers 
with much abundant subserous tubercle." 



IIL — Cases of Cbksbral Bibxasb. 

Case 23. Cerebral hamorrhage ; general arterial ditease of 
peripheral venela; hypertrophied and dilated heart; kidney* 
healthy ; urine normal; death. — James Gr — , mt. 65. Dr. Pary, 
Admitted October 8th, 1879; died October 9tb, 1879. He 
was admitted in an early comatose state, and speedily lapsed 
into a state of complete paralysis. No complete report was 
made of his case. 

Po»t morlem (by Dr. Goodhart). — " Body exceedingly fat. 
Cranial bones very thick and heavy ; the dura mater firmly 
adherent to the skull; arteries of brain very bad; the 
internal carotid on each side very large and standing open 
rigidly. All the vessels were in a similar state, many 
atheromatous aud calcareous plates being studded through 
them. Brain 48 oz. A very largo smash into left hemisphere ; 
an ounce of blood clot was removed. This had torn up tbo 
corpus striatum, and escaped into the ventricle; in addition 
there was extensive ecdiymosis and hsemorrhage into the pons. 
Pleuree healthy. Lungs (Edematous, a little pus in the smaller 
tubes. Intense ecchymosis under the tracheal mucous mem- 
brane throughout its whole length. Heart 22 oz., very 
dilated and hypertrophied left ventricle; both mitral and 
aortic valves markedly thickened at their edges; aorta very 
frir. Arteriw (rf b9tt "pper bb4 lower lipil}9 »therpn}ftto«|, 



, Gooj^lf 



364 Chronic Brighfa Ditease without Albuminuria. 

Vessels of tongue on transverse section very thick indeed. 
Liver lOi oz., fatty, veBsels thick. Spleen 10^ oz., normal. 
Kidneys 15^ oz., surfaces smooth. They contained a few 
minute cysts, but looked very good organs indeed. They 
were very congested, probably from the mode of death. No 
urate of soda in joints of great toe." 

Cabb 23. Cerebral htemorrhage ; general arterial diseate ; 
heart slightly Ht/pertrophied ; kidney t healthy ; vessels thick ; 
urine normal; death, — G. Q — , set. 55. Dr. Wilks (Clin, 
clerk, Mr. Marsh). November 18th j died November 24th, 
I8B0. A carpenter. Has always been steady and sober. Has 
never bad rheumatism. Fatty tumour removed from right 
ahoolder nine years ago. From about this time he has been 
subject to tremor in his right hand and forearm ; this trembling 
has increased lately. For tlie last two or three weeks he has 
had numbness in left leg and foot, especially over heel. No 
fainting fits or other signs of ill health. Was taken suddenly 
with a fit on the day of admission. (The details of which I 
need not relate.) The heart's impulse widely diffused over the 
left half of the chest, There is a diastolic bruit in aortic 
area, heard also in large vessels of neck. The pulse is regular, 
80, and full. (I did not see this case, and therefore have no 
exact note about the arterial pressure.) He had Cbeyne- 
Stokes' respiration. On the day after the fit it was found 
that he had paralysis of left arm, leg, and face, and rigidity 
and tremor of the right. Contraction of left pupil. Hia 
nrine could not be saved on the first two days as he passei) it 
into the l}ed. November 20th. — The urine was drawn off and 
found of slightly acid reaction, sp. gr. 1014, no albumen. On 
the 22nd it had exactly the same characters. On November 
23rd his urine was found to be bloody, probably the results of 
his catheterisation, and it was still more so on the 24th. His 
respirations still continued to exhibit the Cheyne- Stokes' 
phenomena. He died on this day. 

Post mortem (by Dr. Goodhart). — " Spare, grey hair, bald. 
No dropsy. Ttie vessels at the base of the brain had a thick 
opaque appearance, as if sodden in water. There was one little 
patch of atheroma at tbe bifurcatiou of the basilar, but not 
ebewhere. They were really conspicuoas for an absence of 

, Google 



Chronic Brighft Diteaie tnlhotU Albuminuria, 865 

atheroma, though generally thick. The right hemiaphere 
vas filled out and the coiiTolntions flattened ; the membranea 
over the couTolations thicli on both sides. There vaa do 
meniDgeal apoplexy, A sectioD of the brain showed a lai^e 
extravaaation of blood into the right temporo-Bpheooidal lobe, 
converting it into a cyst. Upon making horizontal sections 
of the large ganglia and brain it vaa apparent that the 
htemorrhage had come from a spot is the internal capsule and 
hinder part of the corpus striatum, and had just inTolved a 
small portion of the optic thalamus. All the blood appeared 
to be of one date and recent ; the adjacent brain was stained 
yellow from soakage. The vessels were examined in various 
parts of the brain for miliary anearisms, bat none were found. 
Numerous pnnctiform bsemorrhages on under surface of 
fornix. Lnnga : extreme congestion of both, and early 
broncho-pneumonia. Heart, 12^ oz ; left ventricle perhaps 
a little thick for its size, and in the muscular wall were seen 
small patches of atheroma; the valves were all competent. 
Aorta and vessels ; extreme soft leathery thickening of the 
whole aorta ; the inner surface being rugosn and grey in 
colour; the coats as a whole much thickened. The artery 
was dilated, its circumference being four and a half inches. 
About an inch above the aortic valves, on the couvexi^ of 
this arch, was a vertically elongated aneurismal dilatation 
(about the size of a pigeon's egg). There was another aneu- 
rism at the innominate orifice, of an inch in diameter, the 
great vessels of the neck being very thick. The whole aorta, 
descending as well as ascending, was very atheromatous, and 
the same may be said of the femoral and iliac arteries. The 
radials were also thick and soft, and patched with yellow. 
Stomach and intestine* healthy. Liver, 66 oz., healthy. Gall- 
bladder full. Mesenteric and lumbar glands healthy. Spleen 
6 oz., some thickening of its capsule. Supra-renal capsules 
healthy. Kidneys 12 oz., vessels thick and decidedly athero- 
matous ; the cortex was smooth and looked quite healthy, but 
there were one or two cysts of small size visible. No urate 
of soda in any of the joints. 

The vessels and kidney were reserved for microscopical 
examination, but were unfortunately tbromi away by mistake." 



.y Google 



366 Chronic Brighi'a Ditease wUkout Albuminuria. 

Cabe 24, — Right hemiplegia from cerebral keemorrhage ; 
hj/pertrophied heart ; high arterial pressure ; urine normal.— 
Henry G — , tet. 61. Dr. Wilks. (Clin, clerks, Mr. Warner 
and Mr. A. G. Mahomed). May 11th, 1880— September 
2nd, 1810. A sawyer. Has generally bad very good health. 
Two days before admisaion, on getting ap in the morning, he 
found that he had lost power greatly in the right leg and arm ; 
by the evening be had lost power so much that be was unable 
to stand. On admission be cannot use his right arm and leg 
at all ; tbe leg lies in a helpless condition rotated outwards, 
the arm pronatad. There is very little facial paralysis. 
Sensation is perfect everywhere. Speech is rather thick and 
indistinct, but there is no aphasia. There is well marked 
subconjunctival cedema ; his lower lid is slightly puSy. Pulse 
long, full, and persistent ; requires considerable pressure to 
obliterate it i the vessel is not particularly thickened. 



Heart's apex very indistinct, one and a half inches directly 
below nipple. At apex the second sound is accentuated, and a 
faint systolic bruit can be heard (only in expiration]. The area 
of cardiac dolness is encroached upon by emphysematous lung } 
there is deficient expansion and considerable in-drawing of the 
chest walls during inspiration. Breath sounds are deficient 
over the mai^ins of the lungs in front. He passes bis urine 
more freqaently at night than he used to do ; it ia normal in 
all respects. He slowly but steadily regained strength in his 
right arm and leg, and when he left hospital about three and 
a half months after his attack, he was able to use them very 
fairly well. His pulse tracing taken during August shows 
that his arterial pressure was unduly high ; while his urine 
chart indicates very frequent variations in the quality of bia 
urine, its specific gravity falling at frequent intervals to 1010 
or 1012. Ko albumen was ever discovered in it, but it 
usually gave a clond with tannic aad and peKhloride of 



CAronie Brighft Diteaie vrithoui Al&aminuria. 667 

mercury, and it was observed that this cloud was most dense 
when the specific gravity was lowest. The urine frequeatly 
deposited uric acid crystals. 



QnbUQ. 


8|>.p. 


Bolidi. 


40OL . 


. 102S . 


. 1000 


40 „ . 


. 1027 . 


1080 


«„ . 


. v&e . 


1040 


4t „ . 


10E6 


1080 


«„ , 


. 1087 . 


. 1080 


38.. . 


low . 


. 872 


80 » . 


. 1086 . 


780 



1026 


1000 


1026 . 


. 1100 


1027 . 


. 1850 


1016 , 


. 760 


1012 . 


688 


ICffiO . 


. 020 


1020 


. 1280 


lOlS . 


. 800 


lOlB 


. 972 


1016 . 


. 870 


1016 . 


. 760 


1018 . 


662 



1016 
1016 
lOlS 



1016 
1018 
1016 
lOlS 



.„Gooj^lf 



Chronic Sright'g Diseate without Albumintiria. 



Julj 81 


TOot. . 


1009 


Aag.l , 


. G6 „ . 


— 




. 60,. . 


1016 




. 68„ . 


. 1010 




. M„ . 


1012 




. 60„ . 


. 1012 



lOSO 
1012 
1020" 
1012 



Case 25. Right hemipkgia with partial aphasia from cerebral 
hismorrhage ; thick and atheromatous- vessels ; high arterial 
pressure ; urine albuminous for three days after attack, after- 
wards normal. — ^William O— , tet. 59. Df. Wilks (Clin, 
clerk, Mr. Prentice). Admitted March 9th, 1880; discharged 
April 19th, 1880. Hu father is said to hare died from rheu- 
matic gout. He has had no severe illnesseB. No syphilis or 
goDt. Sixteen days before admission he vas sweeping a road, 
vhen be suddenly felt as if he were dmofc, had to stand 
aguDst a house to prevent his falling. When he came to 
himself he found that he had lost the use of his right arm, 
and partially of his right leg ; bis speech also was thick. On 
admiEsion he is a tall man, with a very red face. Siibcon. 
janctival cedema. Arcus senilis. Partial paralysis of right 
face, arm, and leg, with some aphasia. Chest hyper-resonant, 
cardiac dulness obliterated. Heart sounds distant. Heart's 
impulse scarcely perceptible. Pulse remarkably long, artery 
tortuous and thickened. Urine normal colour, acid, sp. gr. 
1016, allraminons, no sngar. March 12th, — Urine sp. gr. 
1016, still albuminous. After this date albumen was never 
fonod in the orioe ; it was examined and noted on March 
IStfa, 15th, irtfa, 18tb, 19th, 2Srd, 2Sth (sp. gr. 1015), 8Ist 
(sp, gr. 1020), April 6tb, Stb, and 17th. 



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CAronie Bright'* Disease without Alburmnuria. 869 

Case 36. Riff /it hemiplegia and aphasia from cerebral 
haemorrhage ; thick and atheromatous arteries ; high arterial 
pressure ; urine normal. — William S — , let, 50. Dr. Haber- 
shon (Clin, clerk, Mr. A. Scott). October 38th; died 
December 9th, 1879. His father died ia au apoplectic fit. One 
brother faad an attack similar to patient's, was paralysed five 
years, and then died in another fit. Mother died of old age. 
He ia a coffee-stall keeper. Has drank Tcry hard ; was dmbk 
two days before present attack. He was suddenly attacked 
at 5 a.m. on the morning of admission. He jumped out of 
bed and made some inarticulate moans. His wife got up, and 
found that his right leg was drawn up, and the right side of his 
face was " working;" he was standing on his left leg and support- 
ing himself by a chair. His wife helped him into the chair, 
and be indistinctly uttered the words " fit " and " hospital." 
After that he gradually lapsed into a state of stupor but 
occasionally made signs for drink, and the chamber-vessel 
which he used. I need not detail his symptoms; let it suffice 
to say that he had right hemiplegis and aphasia, that it was 
possible to rouse him, but he otherwise appeared in a state of 
stupor. His pulse was 76, hard, and resisting. Brachial 
arteries hard and cord-like. Heart's impulse can only be 
seen and felt in epigastriuoi ; area of duluess normal, sounds 
almost completely obscured hy laryngeal sounds, but seem 
clear. Urine acid, uo albumeu, November 2nd. — Urine, sp. 
gr. 1018, acid, no albumen. Granular casts. It was difHcult 
to get any urine as he passed everything under him. He was 
removed to the infirmary, able to answer questions by gestures, 
but not to speak ; the right arm and leg were flexed and 
rigid. 

Case 27. Right hemiplegia from cerebral hemorrhage ; hyper- 
trophied heart ; high arterial pressure ; urine normal. — James 
G — , «t. 68. Dr. Pye-Smitli {Clin, clerk, Mr. Sturge). 
June 21st — July 2nd, 1879. Father died of dropsy, set. 50. 
Afotber died of mortification of leg after a fall. Has had 
good health till the last two winters, during which he has 
suffered from cough and shortness of breath. He was 
suddenly taken this morning with paralysis of the right 
arm and face and partial paralysis of the right leg. Ue 

YOU zxv. 24 ,-. , 

Dig zecvCiOOJ^If 



S70 Chrome Brighfi DUetue without Albtiminuria. 

nerer lost conscioiuness. Area of ciirdisc dulness increased, 
including left nipple. Impnlae felt plainly in nipple line 
below fiflb nb, and a shock, quite perceptible below sixth rib 
in same Uoe. First sound thick, second normal. Pulse 60, 
foil, throbbing, easilj compressed ; but when the vessel ii 
emptied it cao be felt like a cord and rolled under the finger. 



24 01 



TTrine straw coloured, sp. gr. 1012, no albumen. June 21tli. 
— Urine loaded with lithates. He went out, able to walk 
fairly well, but with considerable weakness of right arm; he 
had recovered his speech. 

Case 28. Cerebral softening ; extremely high arterial pra- 
ture; urine oecanonally albuminout. — Juhn M- — , tet. 62. 
Dr. Habershon (Clin, clerk, Mr. Combe). April 22nd — 
Hay 19th, 1879. His father died at an advanced age of disease 
of the prostate, his mother from chronic bronchitis. One 
brother and two aisters thought to be consumptive; all his 
family are said to be very nervous, but none of them subject 
to any kinds of fits or rbeumatism. Lately he has kept « 
coffee house, formerly a beer-shop. He says he has been 
abstemious, but not much reliance can be placed on him. 
Ever since the age of seventeen has suffered from nasal 
polypi, and has had twenty removed, the last about fourteen 
months ago. About five years ago be noticed that his speech 
was not so fluent as formerly; be seemed to have lost some 
conrrul over bis tongue. Seven or eight months ago be 
found he could not sleep at night, and for three months took 
laudanum, taking at last, he says, as much as ^ oz. at a time. 
During the last two and a half months he has taken chloral 
instead. Six or seven weeks ago he was noticed to walk 
imperfectly with his left leg, which symptom has gradoally 
increased. A well-made man, above the average height (5 ft. 



.yGOOglf 



Chronic Brighl'a Diseaae without Albuminuria, 871 

10^ in.) ; he appeant well nourished, but he says he has lost 
fleah lately. Cardiac dulneas Qormal. Apex beat one inch 
below and to the inner side of nipple. Heart's action 
regular. Pulse 92, and very persistent. The condition of 
this man's pulse was rery striking ; the pulse was long, very 
incompressible, and extremely persistent; the vessel appeared 
to be thickened. Bowels coufined for a week. He is 
extremely forgetful and stupid; he appears to be in low spirits, 
and haa typically the aspect and manner characteristic of 
aoftening of the brain. MoTCments of left leg impaired. 
He is sleepless at nights and very nervous. Urine lOlB, 
fllear, good colour, it contains a trace of albumen. April 
26th. — Sp. gr. 1018, albumen slightly increased. May Ist. — 
Urine, sp. gr. 1020, albunten a trace. April 7th. — Speech 
much better. He is gaining power in left leg. Urine pale 
and clear, sp. gr. 1021, not a trace of albumen. April 
13th. — Urine normal. April 19th. — Contains a slight trace 
of albnmen. He went out, his general condition remaining 
unchanged. July 5th. — He was readmitted with just the 
same symptoms as before; unfortunately, there is no note of 
his arine on this occasion. He went out on August 3rd, 1879. 
In this case the very slight trace of albumen present was over- 
looked till T examined it myself, being led to do so by the very 
extreme arterial pressure. 

Casb 29. Cerebral Boflening ; old l^t hemiplegia ; very high 
arterial pressure ; hypertrophied heart ; low specific gravity ; 
no albumen. — Robert H — , »t. 64. Br. Moxon (Clin, clerk, 
Mr. L. Lane). July 2nd— September 14th, 1879. A clothes 
dealer. For the last seven months his memory has been 
failing him ; he has been in the habit of doing foolish things, 
has been absent-minded aud readily excited to laugh at trifles. 
He has complained much of headache. About four months 
ago he bad sudden hemiplegia and hemiansesthesia without 
loss of consciousness. In about two months he regained 
sensation and partially motion. He is a tall, skinny, blear- 
eyed man, with white hair, looking rather more than his age. 
His temporal arteries are prominent and tortuous; his pulse 
61 per minute, is strikingly persistent, tortuous, incompressible 
and long; the arterial coats are distinctly thickened. Apex 



, Google 



872 Chronic Br^hfs Diseate vnthout Albuminuria, 

bent balf an ioch below and in nipple line. Second sound 
sharp at base. There ib partial left hemiplegia ; sensation la 
normal on the affected side. He complains much of head- 
ache in right temporal region, with some vertigo and con- 
siderable loss of memory. Urine, sp. gr. 1010; no albumen. 
Jul; 14th.— Sp. gr. 1010^ no albumen. Jul; 16tb.— Sp. gr. 
1011, no albumen. July Slst. — Sp. gr. 1011, no albumen. 
July 28tb. — Sp. gr. 1010, no albomea. 

He suffered very severe pain in right temple and right eye, 
tbe scalp being tender on percussion. He was leeched neveral 
times for this with some relief; but he received tbe most 
permanent benefit from s course of purging nith mercurial, 
rhubarb, and podophyllin pill, and a mixture containing 
sulphate of iron and magnesia. No albumen was ever 
detected in the nrine, but the specific gravity was uniformly 
low. He was so forgetful and stupid that he conid not be 
made to save it. 

Casb 30. Attack of tmeonseioutnets ; headache; vertigo; 
hypertrophied heart ; high arterial pressure ; urine normal. — 
Eliza S — , set. 64. I)r. Pye-Smith (Clin, clerk, Mr. Currah). 
December 26th, 1879 — March 26th, 1880. She has had good 
berith all her life. Lately she has been subject to attacks of 
vertigo, and has sometimes been obliged to sit down to prevent 
herself falling. On the day of admission was seized, while in 
tbe street, with an attack of vertigo, and was obliged to support 
herself against some railings ; soon after she fell down and lost 
all consciousness. She does not recollect anything more till 
she found herself in bed in the ward ; she was two hours in 
the hospital before she recovered consciousness. For the Inst 
two days she has suffered from severe shooting and throbbing 
pain in her head ; this pain is increased by movement and 
preuure. She has not lost sensation or power of movement 
in any of her limbs. Heart's impulse alow and heaving, most 
marked in nipple line, in fifth interspace; first sound feeble, 
almost absent, second extremely loud over upper part of 
sternum ; no bruit. Arteries tortuous and much thickened ; 
strong pulsation in episternal notch and in right carotid and 
subclavian. Pulse 70, extremely persistent, long, and rather 
incompressible. 



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Chronic Brigkt't Diteate without Albuminuria. 373 




Preuore 4 oc, Uke« 



Urioe, Bp. gr. 1025, it contains do albumen. Tempe- 
rature 97-8°. While in the hospital she suffered much from 
headache, deafuesa in the right ear, and noises in the head. 
It was some days before she could get up aud about the 
ward. She had a rather severe attack of diarrhtea towards the 
end of January, which seems to have duue her good. The 
condition of her nrine is but seldom referred to, but on four 
occasions it is noted as free from albumen, aud the specitic 
gravity is given as 1025, 1015, 1012, 1014, the last three obser- 
vations being made in March shortly before she went out. 



IV. Cases or Renal Dbopbv, without Aibuuinuhia, 

Case 81. Chronic renal (edema [nmulatinff myxadema) ,- 
high arterial presmre ; general fibrotia ; thickened arleriet ; 
hyperirophied heart ; granular kidneys ; urine normal ; death. 
—William F— , set. 42. Dr. Wilka (Clin, clerk, Mr. 
Starling). November I9th — Died December Slst, 1879. A 
lighterman till three years ago, when he became a night 
watchman on the Swan Pier. Father asthmatical, died at 
80. Mother is now 70, spits blood, has dropsy in the legs. 
Two brothers have died of diahetes. He never drinks beer or 
spirits. He was a strong and healthy man till nine years 
ago, when he had erysipelas, his face then remained swollen 
for ten weeks. When first able to get up and go out after 
this he was seized with pain in his left leg, which laid him 
up for another three weeks. He had gout in his great toe- 
joints two years ago. He had several attacks of giddiness, 
in one of which he fell overboard into the river ; on account 
of this he gave up bis work as lighterman. For the last 
four or five months his memory has been failing him. He 
cannot hold his water for long ; as soon as the call to pass it 
comes, he must micturate or it dribbles from him. 

Patient is a well-developed, well-Qourished maD, com- 



, Google 



874 Chronic Brighl'a DUeaae without Atbumitatria. 

plexioQ florid, hsir spare, fine and straight, tending to bald- 
ness. Evelide very -paSj, face, bands and feet swollen. 
Much capillary congestion of cheeks. Skin thick. The 
swelling is nut like that of ordinary oedema, it ia more 
resistant and elastic. No tophi in ears. Teeth worn down. 
No chalk stones or grating of any joint, though the left great 
toe-joint is painful on pressure. Lungs normal. Apex of 
heart cannot be felt; area of dulnesa is not increased. First 
sound normal, second reduplicated. Pulse 66, regular, long, 
and persistent; pulse tracing shows extremely high arterial 
tension. 




Urine light colour, sp. gr. 1020, no albumen or sngar, acid 
reaction, no casts. Sight good. Ueariog a little defective. 
Voice thick and speech deliberate. Memory bad. 

December 10th. — Complains of more giddiness, pain in right 
shoulder and left hip like rheumatism. December 14th. — 
Sleeps a good deal and does not take bis food well, otherwise 
in same state. The eyelids of both eyes are now as swollen 
as when he was admitted, and hang down when the eyes are 
closed, so that the upper ones droop nearly on to the lower lids. 
Xt has hardly the feel of fluid, more like mucas, though it 
gravitates to the side on which he is lying. December I6th. 
— Coincidently with the appearance of bile in the arine and 
slight jaundice albumen also appeared, but for one day only. 
December 19th. — Nearly all the oedema of eyelids has dis> 
appeared. There is a slight blush on right cheek and above 
eyebrow. Temperature normal. Hands and skin geaerally 
very pale. December 30th. — Cheeks, nose, and region about 
eyes have a diffused red blush, somewhat like erysipelas ; the 
nose is also swollen. Undefined sense of general pain still 
present. December 30th. — Reddish blush on left hip; skin 
not warm, but feels dry, and haa a wrinkled aspect. Needs 
to have any question repeated and shouted to him before be 
answers, and then he speaks in a slow drawling manner. 
December Slst. — I^aat night he rolled about the bed almost 



.yGOOglf 



Chrome Brighfi Diteate wilKout Jibumiauria, 876 

throwing himself off; is veij cold ; Bwellin^ of ejielida 
reappeared, and thej feel as if fall of jelly. Is rery druwsj and 
sleepy, CBonot be roused to answer any questions, even Then 
shouted in his ear; and when told to put out his tongue makes 
a drawling sort of noise, sounding like " What, sir." Falsa 
feeble. He died this day. 

Ilttc QuutitT. Sp. (I. tcMl. Alb. 

Not. 20 ... 38 on. ... 1080 ... 960 ... Nods. 



18 ... M „ ... — ... — ... None. 
Po$t mortem (by Dr. Ooodhart], — "A big man, with puSy 
appearance, and very oedematous state of eyelids. All the 
body looked puffy, but there was no dropsy, no pitting on 
pressure. Id some parte, but by no means in many, or even 
in most, there was a fluid jelly material between the muscles, 
Boms of which I collected. It was mostly in the inter- 
Btnscalar septa of the thighs, and about the pectorals. In 
the subcutaneous fat there was nothing abnormal, no excess, 
no oedema of any kind. The bones of the cranium were a 
little thick and a little rough perhaps. Membranes of brain 
perfectly healthy, and except that one part of the left verte- 
bral was a little atheromatous, there was no disesBo what- 
ever ; they were all thin, good vessels. The brain weighed 
61 oz. and looked remarkably good, but it cut with a peculiar 
toughness, somewhat like cartilage in its resistance, and some 
parts were more so thsn others. I noticed particularly that the 
right cerebellum was so, yet this occorred without any appreci- 
able alteration to the naked eye. The brain looked perfectly 
healthy. I should say, that I had pointed this out before I 
bad any idea of the supposed nature of the case, or, indeed, 

, Google 



876 'Chronic Brighl'$ Diteaae withimt Albuminuria. 

any precoDceptioD in any direction of what I should find in 
the body. The retina in each eye vas perfectly healthy. 
Cervical glands, thymus, and thyroid normal. Costal carti- 
lages healthy. Each pleura contained ■ lai^ qnantity of 
serous fluid, no lymph. Both lungs much compressed by 
fluid in the pleura ; the left lower lobe was quite airless, and 
the right nearly so. With this exception the lung tissue was 
healthy. A very little oedema of the ary-epiglottic folds, 
nothing sufficient to cause obstruction. Mediastinum some- 
what gelatinous. Pericardium contained a good deal of serum, 
the serous membrane wag thick and soddea-loolcing from the 
long-continuing presence of fluid in it. The heart weighed 
15 02. Ita cavities, particularly the left rentricle, were thick 
and dilated ; there was free regurgitation through the mitral 
as tested by water, though the orifice was actually of normal 
size. Tbe muscular tissue was of a peculiar appearancej being 
briivrn in colour and tranBluoeot or gelatinous. It looked 
juicy and streaked with a few fibrous bands. The valves 
were quite healthy and the aorta also. The stomach and all 
the intestines were thickened from an cedematoos condition, 
just such a state as is often seen in old-standing ascites or 
renal anasarca, hut in this case there was no noticeable ascites. 
Liver 93 ox., dark, reddish-brown, firm ; gelatiuona tranalu- 
cency similar to that of the heart. No lardaceons disease. 
Pancreas and mesenteric glands normal. Spleen 6 oz. ; in all 
respects like a heart spleen, firm and dark coloured. Kidneys 
11 oz. ; the vessels were decidedly thick like those of a case 
of Bright's disease, and the organs were dilated like heart 
organs, but except for this they were quite healthy. Capsules 
tbiu, surfaces smooth, cortex in good quautity. Under the 
microscope the kidneys appeared perfectly healthy, but the 
arteries somewhat thickened, especially their adventitia. The 
liver showed well-marked interstitial fibrillation, with but 
little small-celled growth, and much fibru-hyaline exudation. 
The spinal cord did not exhibit any marked changes, beyond 
slight thickening of tbe adventitia of the vessels. Both great 
toe-joints contained a little urate of soda. The knees 
showed senile wasting of the central part of the cartilage. I 
noticed nothing wrong with the tendinous structures around 
the joint, nor in the ligamentum patelle." 

D,9-zec.yGOOglf 



Chronit Briffhfa Diteate mthoui Albuminuria. ■ S77 

Casb 32. Chronic renal dropty ; verg high arterial pres- 
sure; exieiuive retitdlit; wiae normal. — Frederick B— , set. 
47. Came under my care aa aa out-patient on March 21at, 
1881. A tanner. Father died of some surgical affection ; 
mother dead, cause unknown. He had " fits " fifteen years 
ago. He has been ill more or less since 1869, he then had 
what be calls " iaflammation of the brain." He has had 
many abscesses in the bead^ neck, groins, &c. Was in 
Naaman ward in 1877 ; he was then suffering from syphilitic 
ostitis of the temporal bone. He bad pnffiness of the face in 
connection with the local disease, and appears never to hare 
lost it. His urine was always free from albumen, whenever 
examined on this occasion. 

He has a typical renal appearance. Intense annmia. 
Great cEdema of the face and limbs ; the tedema not pitting 
leadilj, especially about legs, where it u hard and brawny to 
the touch. The apex heat cannot he felt, the sonnds are 
indistinct. His pulse is one of very high presanre aa shown 
both by the finger and the sphygmograph. 



There is very extensive retinitis of the right eye, and moch 
atrophy of choroid. His nrine contained uo albumen. Again, 
on March 28th, it is noted that his urine is still £ree from 
albamen. 

Casb 33. 7}oo aiiaeks of renal dropiy toithout ttlbumtnuria ; 
very high arterial pressure ; urine normal. — Ueorge D — , let. 
53. A cellarmao. Came under my care as an out-patient 
in August, 1880. He has generally had good health, has 
never drank freely, about a pint and a half of beer a day. On 
this first occasion he bad typical renal dropsy, but his urine 
was found to be free from albumen. At that time he rapidly 
improved and his dropsy went in abuut a fortnight. On 
Jaooary 17th, 1881, he again attended. His dropsy had been 
coming on for a fortnight ; the weather had been bitterly cold. 
He again presented typical renal dropsy ; face, legs, arms, all 



Dig zee. y Google 



878 Chronic Bright'a Diseate without Albuminaria, 

highly cedematons. Some little cough. Apex beat cannot be 
felt. Second sound highly accentuated. Pulse of high pres- 
sure, hard, and long. Sphygmographic tracing taken, 6 os. 
of pressure required and very high pressure tracing obtained. 
He has never had gout. Atropine was used to fully dilate 
bis pupils, and the fundus vas found to be normal and free 
from hsemorrhages. Urine faintly acid, sp. gr. 1012, no 
albumen. Faint cloud on heating, immediately soluble in 
acetic acid. No cloud with nitric acid. On my expressing 
my surprise to the students, and drawing their attention to 
the fact, be remarked, with some interest " That's what yon 
said before ! " 

Case 34. Acute renal dropty ; high arterial pretture ; hyper- 
trophied heart ; urme normal. — Joseph R — , sat. 43. Dr. 
Hilton Fagge (Clin, clerk, Mr. Griffiths). October 1st — 
October 18th, 1879. A hawker ; has drank freely. Family 
history good as far as it is known. No previous illness. His 
present illness begnn on September 19th (nearly a fortnight 
ago) ; he then noticed his feet were swollen ; he took no heed 
of it for ten days when he came to the hospital, as he found 
his feet and legs getting gradually larger; the swelling be- 
ginning in tbe feet and extending gradually upwards. He is 
a short, stoutly built man, with the puffy appearanse of renal 
dropsy. He feels perfectly well in himself. There is general 
(edema of face, body, and extremities, all well marked, but not 
to an excessive degree. There is a " renal cushion " well 
developed over the sacrum. Heart's apex in fifth interspace 
and in nipple line. Arteries feel thick. Pulse long, hard, 
and persistent. The sphygmographic tracing shows veij high 
arterial pressure. 



Pre«rore7<». 

The urine is clear and free from albumen, at drat of low 
specific gravity and of excessive quantity, Tbe cedema soon 
disappeared and tbe pulse showed a reduction of arterial pres- 
sure. He went out quite well. 



lized^yGOOglf 



Chrome Bright** DUeate without Alintminuria. 



76 o». ., 


,. 1010 „ 
,. 1012 .. 


900 


80 „ .. 


.. 1012 .. 


»60 


B8 „ .. 


.. 1018 .. 


,. 1066 


M, ., 


.. lOlB 


. 1380 


9B „ . 


.. 1012 „ 


. 1776 


80., ., 


,. 1018 .. 


14M 


90 „ . 


.. 1017 .. 


.. 1630 


90 „ . 


.. 1020 ., 


,. 1600 


M„ - 


.. 1019 .. 


. 1748 


99 „ . 


— 


_ 


M „ ■ 


.. 1019 


1216 


92 „ . 


.. 1019 .. 


1748 


es,. . 


.. 1020 . 


.. 1360 


78,. . 


.. 1020 . 


.. 1660 


40 „ . 


.. 102a .. 


820 



17 

Caic 35. Acute renal congestion u4lh renal dropty ; faint 
trace of albumen for two dayt ; hypertrophied heart ; thick 
arteriee ; high arterial preaaure. — William T — , fet. 48. Dr. 
Moxon (Clin, clerk, Mr. Duckworth). Admitted October 
14th, 1B80. Dischai^ed October Slst, 1880. He is a cora 
porter, Knd has always drank besvily, ta&aj pints of beer and 
aereral glosses of rum a day. No serious illnesses. Nine 
days before admission he felt cramping pains across his 
loins. His scrotum, penis and ankles became swollen. He 
noticed that he passed less water than usual. On admission 
he is a big, bloated-looking man. HiscgDJunctiTSB, face, legs, 
ankles, scrotum, and penis are all oedematous. There is a 
little fluid in the peritoneal cavity. There is crepitation at the 
bases of both lungs behind. The heart is somewhat enlarged ; 
the area of duloess is increased. Apex heat indistinct. First 
sound prolonged; there is an occasional systolic bruit. 
Arteries somewhat thickened. Pulse persistent, small, and 
compressible. The liver is enlarged, reaching two finger's 
breadths below ribs. Spleen normal. Tongue fairly clean. 
Bowels regular. Appetite good. The urine is pale, sp. gr. 
1020, contains a trace ot albumen, October I5th. — Anasarca 
less general. Only a trace of albumen in urine. October 
16th. — The dropsy of trunk, face, scrotum, penis, &c., has 
disappeared. Patient looks well. Appetite is good. Bowels 
regular. The orine is free from albumen. After this the 



„Gooj^lf 



880 Chronic Briffhfa Disease without Albuminuria. 

albumen never again appeared, and he was discharged on 
October Slat apparently well, though the histor; of alcoholic 
excesses, his bloated, unhealthy appearance, the enlargement 
of his heart, and the thickness of his vessels all give evidence 
of the chronic natnre of his renal disease. 



40 „ 


.. 1016 . 


640 


60 „ 


.. 1020 . 


1200 


M ., 


.. 1020 . 


. 1040 


60 „ 


1024 . 


1440 


62 „ 


-. lois . 


1196 


40 „ 


.. 1028 


880 


40 „ 


— 


— 


40 „ 


... 1033 . 


. 880 


40 „ 


.. 1020 . 


800 


S6 ., 


... 1020 . 


720 



29 ... 83 „ ... 1020 . . 640 ... „ 

Case 36. General eedema ; hypertrophiad heart ; high 
arterial pressure; urine normal. — W. H. C — , set. 46. Dr. 
Moxon (CHd. clerk, Mr. Rowlauds). July 14th — August 4th, 
1B80. He is sfiid to have been more or less troubled since 
childhood with some eye aSection and headache, otherwise 
has had tolerably good health. Twenty-six years ago he had 
gonorrhoea, a soft chancre, and bubo, with a slight sore but 
no rash. About five months ago the sight in both eyes began 
to fail, and he had a slight brow-ncbe at the same time ; did 
not improve under treatment, but sight has been getting 
worse up to admission. For the last fortnight he thinks 
he has been losing power in his legs and hands. He 
is an ansemic-lookiug man, with a puffy face and dark hair 
and eyes. Complains of slight pain in the head and a sense of 
heaviness over lower part of chest. He is said to have want of 
power in hands and legs ; he seems to stagger a little in 
walking. He complains of a slight sense of numbness in his 
feet. There is no defiaite paralysis, bat there is a lack of 



Dig t,zec.y Google 



Chronie Brigkt'$ JHtease wiihotU Albumitmria. 881 

energy about all his inovemeDts ; this has been coming on a 
fortnight or so. There is no ansesthesia. Patellar tendoo- 
rcflez very slight. He ia nearly blind. These are all the 
symptoms of nervous disease. On the other hand, he has welU 
marked general cedema ; his face is distinctly puify ; there is sub- 
conjunctiral cedema, aedema of the thorax, feet, and legs; behind 
there is a Tery distinct " renal cushion." The apes beat of the 
heart can only be felt with difficulty ; the impulse is decidedly 
external to nipple ; the second sound is highly accentuated. 
False long, persistent, and compressed with difficulty. The 
tracing obtained is highly characteristic of Bright's disease 
with very high arterial pressure. 



Preunre 4 ox, 

nis optic discs are pale and watery looking, as thongh 
cedematous. There are no retinal hemorrhages. His eyes 
were examined by Mr. Higgens, who reported as follows : — 
" Doubtfnl perception of shndows ; slight conrergent strabis- 
mus, appareutly from weakness of external recti. Optic discs 
pale; outlines ill-defined." He remaiued in the hospital three 
weeks, without any material change in his symptoms. On 
August 3rd, the day before his discharge, the following note 
is made : — " Patient is stronger on hia legs. Feet and legs 
more cedematous. Does not complain of any subjective sensa- 
tions this week. His urine was examined daily. It was 
clear, amber coloured, it never contained albumen, nor could 
any casts be discovered.'' 

Date QnintitT. Sp, gr. SoUai, BdveU tcUd. 



.y Google 



Chronic Bright't Diaeaie without AlbHminuria. 



28 01. 


.. 1018 


S2 „ 


.. 1018 


16 „ 


.. 1012 


82 „ 


.. 1016 


i*,. 


.. 1018 


** ,. 


.. lOlE 


40 „ 


.. 1018 


40 „ 


.. 1018 


20 „ 


.. 1028 


22 „ 


.. 1082 


80 „ 


1018 


40,. 


.. 1018 



Case 87. — Chronic bronchitit and emphytema ; general 
adema ; high arterial preuure; degenerate vetath ; urine 
normal.— 3o\\n 1) — , »t. 43. Under Dr. Pavy (Cliu. clerk, 
Mr. Lawson). January 25tli — April llth, 1880. Has 
suffered from cough for tbree or four years, which has become 
worse lately. There has occasionally been bright blood mixed 
with sputa, especially in the spring time. Has noticed that his 
breath smelt badly during the last two or three months. He 
has had dyspnoea for two years, but this has been much worse 
for the Inst six weeks. On admisaion, he has a puffy and 
cyaaosed face, much subcoujuDCtival oedema, oedema of legs 
and trunk, a well-marked reual cushion, and some ascites. 
Hands wasted, and fingers clubbed by prolonged cyanosis. 
Liver enlarged and tender. His breath and sputa are 
extremely offensive. Chest emphysematous in shape and 
hyper-resonant. Bronchitic sounds throughout both lungs ; 
small crepitations at both bsBes. Heart's impulse felt in epi- 
gastrium and diffused over a large area; apes cannot be 
locahsed ; loud and accentuated second sound, feeble first. 
Very thick and degenerate arteries; the radials are tortuous 
and beaded. Pulse incompressible. Gets up two or three 
times at night to micturate. Urine, sp. gr, 1015, so alba- 
men. March 3rd. — Lips purple. Heart's action intermittent. 
No albumen iu urine. March 4th.' — Urine, sp. gr. 1025, do 
albumen. March Cth and 8th. — No albumen. The farther 
record of urine appears in the following table. 



Dig lized^y Google 



CAronic Bright's Disease wilkoul Aliuminuria. 383 



Salhli. 



1030 ... 1200 

1030 ... 1200 

1026 ... 1550 

1026 ... IISO 

1026 ... 12S0 

1020 ... lOSO 

1030 ... J600 

1020 ... 1200 

1020 1240 

1020 ... 1280 

1020 .., 1200 

1020 ... 1180 

1020 ... 1220 

1020 ... 1400 

1025 ... 1650 

1028 ... 1736 



During his stnj ia hospital he was troubled by beiog abla 
to pass only a small quantity of urine at a time, only three or 
four ounces. His heart, on several occasions, was very irre- 
gular. When he left, on April 11th, he was still very ill. 



Case 38. — Chronic Rachitis and emphysema ; renal dropsy ; 
rather high pressure ; albuminuria on three occasions, usually 
normal urine. — Louisa L — , set. 50. Dr. Fagge (Clio, clerk, 
Mr. Perks). January 11th — February 5th, 1881. Family 
history uncertain. She has bnd winter cough for many years. 
About one year ago she was laid up with swelling of chest and 
abdomen. Was better during the summer, but a day or two 
after Christmas she was again seized with cough, difficulty of 
breathing, and swelling of feet, face, and hands. An eitremely 
fat, flabby woman, accustomed to drink gin, at least two glasses 
a day ; superficial vessels of face and of conjunctiva dilated and 
varicose, (Edema of conjunctiva, feet, and hands. A small 
amount of ascites. There was harsh breathing, prolonged 
expiration, a few moist sounds, with sibilant rlionchi all over 
chest. The apex beat was in fifth interspace, about three 
inches from sternum. Cardiac dulness normal. No visible 
pulsation. First sound distant, heard best at apex, very dis- 
tant over lower extremity of sternum. Second sound sharp 
utd accentuated, especially at apes. No bruit. Pulse regular> 



884 Chronic BrighPa Disease without Albtarunaria. 

rather long, hard, not very compreasihle. Pulse tracing, tnlcen 
on January I8th, indicates blood pressure but little above the 



average. Liver not ealarged. Urine was found to contain 
albumen, which disappeared the next day, and was only 
present on two subsequent occasions. 



QoimlilT. 



Bp-ji. 



... 6 01 


(P)... 


1020 ... 


664 


.. i 




... 87 „ 




1018 ... 


666 






... 43 „ 




1018 ... 


774 


n 




... 4fi „ 


... 


1020 ... 


920 


„ 




... 86 „ 




1016 ... 


476 







... la ., 




1016 ... 


830 


. 




... »e„ 




1018 ... 


648 


n 




... 29 ., 




1016 ... 


464 







... 26 „ 




1016 ... 


890 


. 




... 38 „ 




1015 ... 


670 


H 




... 81 „ 




1018 ... 


668 


.. 




... 28 „ 




1016 ... 


448 


. 




... 27 » 


... 


1018 ... 


486 


„ 




... 24 „ 




1020 ... 


4S0 


„ 




... 28 „ 




1018 ... 


624 


. 




... 28 „ 




1018 ... 


624 


« 




... 36 „ 


Go 


DP to-daj 


— 


. 




... 20 „ 


... 


1020 ... 


400 . 


. -A .. 




... 32 „ 




1011 ... 


676 


. None .. 




... 28 „ 




102B ... 


616 


. 




— 




1024 ... 


_ 







— 




1020 ... 


_ 


» 




— 




1018 ... 


_ 


,. 




... — 




1020 ... 


— 


. Slight.. 

ClODd 




— 


... 


1018 ... 


— 


. None .. 




— 




1022 ... 


_ 


» 





ExceplioQ may, perhaps, be taken to this case ; its nature is 
certainly not well established, neither hypertrophy of the 
heart nur high arterial pressure being demonstrated ; yet the 

Dig lized^y Google 



Chronic Bright*! Diseate without Albuminuria. 385 

irell-niarked renal drops; and the presence of albumen ou 
three occasions have been taken as sufficient evidence to 
warrant its being cUsaed in this group. 

Case 39, Epileptiform attack ; uramia (?) ; kypertrophied 
and dilated heart ; high arterial pressure ; slight general 
oedema ; urine normal. — Frederick F — , tet. 56. Dr. Pye- 
Smith (Clin, clerk, Mr. Hind). December 7th — Decern- 
ber 29th, 1879. A cabdriver. Family history good. He 
says that he has been subject to epileptic fits as long as he 
can remember, for the last few years having one about every 
t70 years. When an attack comes on he first feels dizzy and 
then becomes nnconscious ; is generally ill five or six veeks 
after each attack; sajs he has drunk heavily years ago, both 
beer and spirits. On the night of December 6th was walking 
over Blackfriars Bridge when suddenly he felt dizzy and 
fell down ; knows nothing more until he found himself in 
Guy's. I saw him the nest day, and made the following 
note : — " He looks like a man who liaa drunk beavily, 
his face is red and bloated ; he has the appearance of one 
suffering from so-called 'uraemia'; he is semi-conscious and 
muddled, his movements are slow and feeble ; he is lying low 
in his bed and on his back. When asked a question he 
makes some absurd answer, rambling on in an incoherent 
manner ; be can only be roused with difficulty to make even 
this eSbrt. His pupils are contracted, and do not react to 
variations in light. There is well-marked subconjunctival 
oedema, general puffiness of the face, especially of the lower 
eyelids ; there is slight cedema of the hands and legs. He 
has an ammoniacal smell. Pulse typically that of chronic 
Bright's disease, 76, regular, very persistent, incompressiblcj 
and long; artery thickened. Heart's apex beat greatly dis- 
placed, faintly felt below sixth rib and 1^ inches external to 
nipple ; systole short, like that of dilatation." Uriue, sp. gr, 
1025, clear, reaction slightly acid, contains no blood, albumen, 
or sugar. Temp. 98'4°. 

December lOtb.— -Complains of pain in his head; seems 
very drowsy. Dec, 11th. — Urine 1025, no albumen or 
blood. Seems a little better. Dec. 12th. — More sensible, 
and answers questions rightly. Still complains of pain in hii i 

VOL. XXV. 26 V^" 



386 Chronic Brighf$ Diteaae withotd Albuminuria. 

head. Bee. 14th. — Urine healthy. Hai no oedema of hands 
or legs. Dec. 16th. — Urine 1030, clear, no albumen, blood, 
or Bugar, No oedema of legs. Dec. 24tb. — Heart soiinda 
have a somewhat tic-tac character; second sound accentuated 
at base. Coarse breathing, long expiration, and some rhonchus 
scattered all over chest. Dec. 27th and 29th. — Urine, sp. gr. 
1020 and 1015, no albumen. He left on the latter day, still 
complaining, however, of paia in bis head. 



V. Cases with Godt, 

Case 40. — Plumbum ; goal ; renal dropsy ; high arterial 
prestvre ; trantient mitral regurgitation; urine normal. — 
Robert D— , set. 86. Dr. Pye-Smith (Clin, clerk, Mr. 
Gardner). August 13th, 1879— January 20th, 1880. A 
shoemaker, no reason for the lead poisoning discovered, beyond 
a habit of putting nails into his mouth when rivetting, and the 
fact that the leather is cut on lead before it comes into his 
hands. He has been a hard drinker. He was more or less 
unwell in November, December, and January, during which 
months he had " colds," pains in bis back and limbs, and a 
short pyrexial attack. Towards the end of January the fingers 
of his right hand became oseless and his right wrist dropped. 
During the last four or six weeks his left wrist also became 
affected. On admission he is suCFering from paralysis of the 
extensors of both forearms; he is ansemic, has a well-marked 
blue line on gnms. His joints are unaffected. The second 
sound of the heart is loud and sharp, and can he heard all 
over the right side of chest. The clerk describes his pulse as 
" very weak," but I have no special note about its characters. 
Although the urine was saved and measnred daily no notes of 
its characters are recorded. I believe that it may safely be 
assumed to have been normal as my attention had been espe- 
cially directed to the fact at the time. During August and 
September his paralysis slowly but steadily improved under 
the use of the continuous current applied daily. 

October 11th. — Has been taken ill to-day with sicknesa and 
diarrhoea after eating a quantity of grapes. 

]3tb. — Says he feels very ill this morning, compIainB of 

I . . Google 



Chronic Brtght't DUttue without Albuminuria. 387 

coD8t&nt sicknesB and dianrhcea. Tem^Krature 96-8''. Fulee 
108, strong, r^;nlar, and incompressible. 

16th. — Is all right again this morning. 

17th. — This morning he is Ipng in bed with the scrotum 
greatly svoUen and cedematoiiB. The legs are also slightly 
cedematooa. No albumen in nrine. Slight bruit heard at 
apex. 

32nd. — I note that — " He looks intensely renal. A pale, 
pasty, and cedematous-looking &ce. A ' renal cushion ' over 
sacrum ; scrotum and legs cedematous. Urine, no albumen, 
uric acid deposit. Pulae persistent, but not long. Apex 
beat perceptible, but not displaced, first sonnd inaudible at 
apex, replaced by a so£t systolic murmur ; second, intense and 
tympanitic at apex, more so than at base." The urine was 
saved, measured and tested daily from now till November 16th. 
He steadily improved. 

November 6th. — Feels much better now, but still compluns 
of cramp in his fingers and toes. No bruit can be heard at 
apex now ; the urine contains no uric aoid, and the legs are 
not (edematous. 

On December 8th he had an attack of gout in his feet 
which laid him up for three days ; this recurred on January 
8th, after this be steadily improved, and when he left he had 
completely regained the power of the wrist. 

The nrine table appears to be very inaccurate as to the 
number of ooncea passed, and it can only be relied on to 
represent a minimum quantity. 

During the whole of December the quantity of urine passed 
is recorded, but its specific gravity only occasionally, when it 
is also noted that it contains do albumen. 



10C6 
1020 
lOK 



102S 
102G 
1025 



Dig zec"y Google 



Chronic Bngkl*a Disease wilhout Albuminuria. 



,«Bli.J. 


Sr-gr, 


Solid!, 


Mm. ., 


,. 1026 .. 


600 


40 „ ., 


. 1025 ,. 


1000 


60., .. 


. 1025 .. 


. 1500 


28 „ .. 


1030 


840 


32 ,. .. 


. 1027 .. 


766 


20 „ .. 


. 102& .. 


COO 


80» ,. 


. 1028 .. 


840 


20 „ .. 


. 1007 .. 


140 


12 „ .. 


.. 1023 .. 


. 276 



Case 41, — Plumbism ; gout; hyperlrophied heart; mitral 
regurgilation ; bronchitis ; epistaxis ; urine normal.~~-Thos. 
M— , let. 48. Dr. Wilks (Clin, clerk, Mr. W. Spong). 
January 31st — February 28th, 1880. A paperhanger RDd 
painter. Has nerer had scarlet or rheumatic fever. First 
attack of gout four years ago. Winter cough for last twelve 
years. Has drunk freely. He came in for cough associated 
with severe epistaxis. He is described as a sparely built man, 
fairly well nourished, medium height and weight. Somewhat 
autemic, pasty face, well marked subconjunctiral cedema, lower 
eyelids puffy. Hair dark, no beard or moustacbe. Eyesight 
good, sclerotica clear. No annsarca of lower extremities. 
Complains of sickness in the early morning with loss of appe- 
tite ; eyes watery on rising; blue line on gums. (Has 
worked a good deal in lead, never had colic.) Extent of pre- 
cordial dulness not increased. Apex heat can be felt half an 
inch below and in nipple line; systolic bruit can be heard 
at apex and there only, very faint and somewhat high pitched. 
Pulse regular and compressible. Unfortunately I have no 
actual note of my own about the pulse in this case, and the 
report does not state whether it was persistent or not. But 
my memory of the case is sufficiently clear to assert that it 
was one of high pressure. Has not passed much water lately. 
Urine light colour, clear, no deposits, sp. gr. 1022, no albu- 
men, sugar or blood. 

February 2nd. — Epistaxis again commenced severely. 

3rd. — Is still troubled with epistaxis at times. Persistent 
headache. The bruit is more audible to-day. 

I6th. — No return of epistaxis since the 4th. Cough more 
troublesome, expectoration muco-punilent and streaked with 

Google 



Chronic Bright't Disease without Albuminuria. 389 

blood. Air aaid to enter left lung better tban right ; expira- 
tion prolonged at left apes. There was thought to be a little 
deScienc; of resonauce at this spot, but thie was not confirmed 
by Bubsequent obseryations. 

20th. — Bruit scarcely audible to-day. 

24tb. — Scarcely any cough or expectoration. 

36th. — Gout in hand and foot, which subsided in a day or two. 
His urine never contained albumen. The evidence of vascular 
dtseane is not very satisfactory in this case, but his charac- 
teristic appearance and puffy face taken together with the fact 
that be had both gout and lead poisoning, make the diagnosis 
of grnnular kidneys and vascular changes very probable. He 
had DO history of rheumatism to account for his mitral bruit, 
which was therefore probably due to leakage from an over- 
distended ventricle ; the variable intensity of the bruit vould 
seem to bear this out. His epistaxis and severe headache are 
characteristic of Bright's disease. 



1022 
X018 
1018 
1016 
1017 
1020 
1018 
1017 
1018 
1017 
1016 
1018 
1020 
1020 
1022 
1020 
1015 
1020 
1020 



z.c:,y Google 



S90 Chronic Bright'^ Diseaae without AJbuminwia. 

Casb 42. Oovt ; hypertrophied heart; thiek vetieli; high 
arterial presiure ; traruient albuminvria, — WilliRm M — , et. 
46. Dr. Moxon (Clio, clerk, Mr. Trott). September IStfa — 
October 4th, 1879. Father dead, cauae unknown. Mother 
died of dropsy. One sister rbeninatic. Four years ago 
patient had " rheamatism '' in both ankles and slightly in 
elbows and shoulders. He now complains of severe puns in 
great toes and swelling of legs, with pains in several other 
joints. Never had crackling in joints, A strong-looking 
man with capillary injection of cheeks. There appears to 
be some bronchitis. The apex of the heart beats two inches 
below nipple, first sound at apex long, second sharp and accen- 
tuated. Pulse incompressible, full, and persistent. Arteries 
thick. There is no accotint of the condition of the joints bnt 
the disease was diagnosed as ^ut; it wastreated and relieved 
by colchicum. The condition of the urine is recorded as 
follows : 

TUIt. qDinlllT. Sy.p. flolidi. Alb. 



1019 


616 


Some. 


loio .. 


400 , 




loao 


320 . 


.. A little. 


1020 .. 


400 . 


.. Slight trace. 


1010 


800 . 


No .lb. 


— 


— 


None. 



60. . 


_ 


M., . 


1010 


«« . 


.. 1016 



Cask 43. Gout ; bronehitif ; hypertrophied heart ; high 
arterial pretittre ; urine normal. — Charlotte F — , sat, 61. 
Dr, Taylor (Clio, clerk, Mr. J. B. Howell). Jannary 21st 
— March 30th. 1881. She was admitted into the hospital 
for bronchitis and chronie gout, she has been in twice before 
with the same compltints. Has had no other serioos illnesses. 



Chronic BrigAt's Di$ea$e without Albuminuria. 301 

She is a well-nourished voman, with a slightlj Suthed face, 
and BOme dyspncea. She has well-marked gout in the right 
hand and both feet, and a good deal of bronohitia, rhonohaa 
and mncous r&les being scattered over the cheat. The apex 
of the heart can be felt one and a half inch below and in a 
vertical line with the oipple. Priecordial dulness not increased. 
Heart sounds normal. Urine very pitle, sp. gr. 1016, acid 
reaction, slight precipitate on boiling, dissolved immediately 
by nitric acid. She passed through a severe attack of gout, 
which attacked several joints and therefore gave rise to a 
snspidon of the disease being rheumatism. Durisg March 
she had tax attack of severe abdominal pain, which appeared 
to be caused by some Cfecal troubles. The accompanying 
tracing obtained from her pulse in the early part of March 
affords good evidence of her very high arterial pressure. 



Her urine was carefully watched during the month of 
March and appears to have been always normal. The 
quantity of urine saved is very deficient, this was probably 
due to want of care in preserving it, a difficulty more espe- 
cially felt in the female wards. 



Burtili. 


3p.sr, 


SoUii. 


AO. 


Bi><re1(. 












B4 oz. 


... 1022 .. 


. 688 ., 


.. None 


... 2 


24 „ 


— 


— 






20 „ 


... 1020 .. 


. 400 .. 


„ 




18 „ 


... 1020 


. 360 . 


.. 


... 1 


22 „ 


... 1020 .. 


440 , 


n 


... 1 


32 „ 


... 1016 .. 


490 . 


„ 


,., 1 


28 ,. 


... 1016 ., 


— 






ao „ 


... 1016 


460 


.. 





.„Gooj^lf 



Chronic Brighl't DUease leUhout Albuminuria. 

QuiistilT. Sp, gr, Soliili. Alb. B 

7 ... 31 ox. ... 1012 ... 40S ... None. ... 

S ... 28 „ ... lOlS ... 420 ... „ ... : 

) ... S2 „ ... 1016 ... 480 ... „ 

) ... S6 ,. ... — ... — ... „ ... I 

I ... 82 „ ... 1010 ... 820 

i ■ ... S8 ., ... 1012 ... 466 : 

1 ... SS „ ... 1012 ... «6 ... „ 



Case 44. Oiteo-arthritia (gouly) ; hypertrophied heart ; 
high arterial presture ; remarkable family history of apoplexy ; 
urine normal. — Sarah L — , at. 51. • Dr. Wilka (Clio, clerk, 
Mr. W. Spong). Jaouary 2nd— February 23rd, 1880. 
Her mother was Bubject to " rheumatiBm ; " she had BeveD 
children, and died of apoplexy when thirty-nine. Patient is 
the only surTiving child. TwosiBters and one brother died of 
apoplexy, aged respectiTely fifty-one, thirty^one, and 6fty. 
The three other children died when qaite young. The patient 
has always had good health until sixteen years ago, when she 
was first troubled with what she calls rheumatic pains in most 
of her joints. For the last year or so she has been gradually 
getting more crippled, and has lost flesh considerably. Four 
years ago she aays she had inflammation of the lungs, and 
was confined to her bed for three months. For the last few 
years she has had winter cough. For three weeks before 
admission she has been confined to her bed with pain in 
various joints. She has a pale, tLntemic, pasty face ; pnfly 
lower eyelids, much subconjnnctiTftl oedema. Very many 
of her joints are severely and characteristically distorted 
by osteo- arthritis. There are some signs of bronchitis in the 
chest. Apex beat forcible and heaving, it is somewhat die- 
placed, it is felt best in the fifth space and in Hoe with the 
nipple. Cardiac duluess not increased. Ko bruit audible ; 
second sound intensely accentuated. Polae 84, characteristic 
of very high arterial pressure; arterieB extremely thick. 
Urine light in colour, no deposits, and no albumen. The 
urine chart appended shows that its specific gravity was 
usually low, commonly only 1010, its quantity was rather 
increased if anything, it never contained a trace of albumen. 
She went out much as she came in. 



Dig zee. y Google 



Chrome Brtght'i Disease without Jibumimtria. 



Case 45. Gout; 



0*. . 


.. 1012 


... (600 ... 


None. 


» 


.. 1012 


... 876 ... 




,. ■ 


.. 1020 


400 ... 


„ 


•• 


.. 1016 


S62 . . 


„ 


- . 


.. 1016 


... 862 ... 


„ 


„ 


.. 1017 


... 680 ... 


„ 




.. lOlS 


— 


„ 




.. 1012 


... 672 ... 


„ 


.. . 


.. 1014 


... 682 ... 


„ 


!• 


.. 1014 


280 ... 


„ 


u 


.. 1012 


... 836 ... 


_ 


» . 


.. 1012 


860 ... 


„ 


» 


1012 


... 386 ... 


„ 


„ . 


.. 1010 


200 ... 


„ 


» 


.. 1012 


... 264 


„ 


„ . 


1014 


322 ... 


„ 


J. 


.. 1010 


... 600 ... 


„ 


» 


1012 


480 ... 


„ 




.. 1012 


... 628 ... 


„ 


„ . 


.. 1020 


... 400 ... 


■■ 




.. 1012 


... 662 ... 


„ 


n '. 


.. 1010 


280 ... 


„ 


n ■ 


.. 1010 


... 800 ... 


„ 


.. 


1010 


600 ... 


„ 


.1 


.. 1012 


... 480 ... 


„ 


II 


.. 1012 


... 456 ... 


„ 




.. lOU 


... 660 ... 


„ 


„ . 


.. 1010 


... 600 ... 


" 


" 


".. 1012 


... 676 ... 


„ 




.. IDIO 


... 660 ... 


„ 


H 


.. 1010 


... 400 ... 




» .. 


1010 


600 ... 


„ 


» 


.. 1011 


694 ... 






.. 1010 


,.. 600 ... 


» 


;; 


.. 1012 


... 668 ... 


„ 


.. . 


.. loia 


... 676 ... 


» 




.. 1012 


480 ... 




» 


.. 1010 


... 600 ... 


„ 


» 


.. 1012 


888 ... 


„ 


,, . 


1016 


... 460 ... 




rena/ dropsy i 


hypertr<^hied 


heart i high 








■ , Googk 



894 CAronie Brighfa Diieate without Atbuminttria. 

arterial pressure ! urine normal. — Robert D — , at. 66, Dr. 
Pary (Clin, clerk, Mr. Bolton). July Srd — September 8rd, 
1880. Subsequently under my own care as an out-patient. 
His father died of " goat in the Btomacb." He has been 
subject to attacks of gout since be was twenty-eight years old, 
if not before. He was in Gujr's Hospital in 1877, suffering 
from gout. His urine was then normal. He is a tall, veil- 
made man, but his joints are greatly deformed by gout. He 
baa oedema of his face, legs, and scrotum, iind it was this that 
caused him to seek admission. He has considerable dyspucea 
oil exertion. Has to rise many times at night to micturate. 
Apex beat 2^ iDches below nipple and one inch external to 
mammary line ; first sonnd normtd, second intensely tympanitic, 
beard iridely all over the chest. Pulse persistent and Jong, 
Artery is not recognisably thickened. Urine free from 
albumen. July 9th. — The urine is carefully examined daily 
for albumen ; there is no trace of it, July 16th. — No trace of 
albumen ; urine passed last twenty>four hoars, 44 oz. Unfor- 
tunately, no complete record of the urine was preserred. The 
patient came under my care as an out-patient on January 
31st, 1881. He had then no oedema ; bis urine was free from 
albumen ; he had great hypertrophy of the heart. Apex beat 
1^ inches external to nipple and about 1 inch below. 



VI.. CaSXS with SEVEftE EPISTAXIB. 

Case 46. Severe ejnitaxis ; lumbar pain ; puffy face ; very 
high arterial pressure ; oecanonal albuminuria. — Richard R — , 
let. 48, Dr. Pary (Cliu. assistsnt, Mr. Udale). January SOth 
— February 7th, 1881. The following case did not come 
under my own personal obserration, but its carefully recorded 
details makes it of great value. For the last fire years the 
patient has been subject to attacks of rheumatic gout, t.e. 
severe pain and swelling, commencing in the big toe, after- 
wards appearing in the kuee, hands, &c. Except during these 
attacks his legs and feet have never swelled. Has suffered at 
times from an aching pain in the lumbar region. Sometimes 
his eyes get puffy. Has vomited in the morning on getting 
up, about once or twice a week, though some weeks not at all. 



„Gooj^lc 



Chronic Brigkt'a Diteaae without Albuminuria. S96 

Some palpitation of the heart oa exertion but not enough to 
cause much diatreas. After reading for some time his sight 
becomes hazy. Now and then he feeln giddy, and bis head 
swims. Frequent micturition, hut little at a time. 

January 27tb, while at work, bis nose began to bleed and 
contioned for some time; this was repeated on the following 
day. On the 29th the bleeding whs bo profuse that he called 
io a medical man who plugged the anterior nares; this did 
not quite stop the bleeding so he applied to the hospital. 
When brought here he was very pale, almost pulseless, and 
in a cold sweat. He brought up a quantity of blood which 
he bad swallowed, and while in the surgery he fainted. The 
patient is a strong, well-built man. Skin warm, dry, and 
ansmic. Conjunctivte slightly oedematoua. Slight effusion 
into left knee. No oedema of legs, &c. Slight rhonchus on 
deep inspiration, otherwise the lungs are healthy. Apex heat 
in normal position, no increase of cardiac dulness. A soft 
systolic bruit is heard indistinctly at the apex, which is more 
distinct at the base and on the right side of the sternum. 
Pulse atrong, full, but compressible, very persistent, feeling 
like a cord rolling beneath one's fingers. Pulse regular. 



Urine rather dark amber coloured, acid, sp. gr. 1012, cloud of 
albumen on boiling, no sugar, about seven grains of urea to 
the ounce. 



DM*. 




Sp.ir. 


Solid!. 


Vm. 


Albinun. 


Jan. 80 


.. — 


. loia . 


Z 


.. 7BrB.tooi 


... A trace. 


31 


— 


— 


. — 


— 


... SUght. 


Feb. 1 


.. - . 


■ - ■ 


— 


- 


... Very rilght. 




.. 48ox. . 


. 1018 . 


646 


.. 7-92 per 01 


None, 




.. 61 „ . 


_ 


— 


— 


» 




.. 32 „ . 


. — 


. — 


.. 7-48 pert* 




6 


. 61 „ . 


1013 . 


6S3 


.. 6-82 „ 


... SU^traoe 
with heirt, aane 
witboitriea^d. 



D„t,i.a,Google 



896 Chronic Bright'a Diteate wnthout Albuminuria. 

Case 47. Severe episiaxts ; chronic bronchitis and emphy- 
tema ; thickened and degenerate vessels ; urine normal. — John 
P — , set. 54. Dr. Pye-Smith (Clin clerk, Mr. Goaae). 
NoTember 29th, 1878— January 9th, 1879. A builder's 
labourer. Family history unknown. Has always been a very- 
heavy drinker, more nhisky than beer. Up to five years ago 
he enjoyed good health, except for a continued fever twenty- 
seven years ago. Has never had rheumatism. Five years 
ago he had a fall on his left side and broke three ribs ; he 
was laid up for five weeks, and then weut to work again ; 
has always bad slight pain in bis side since. Four years ago 
was his next illness, when coming home from work one even- 
ing he had violent epistasis ; it lasted for five or six hours. A 
doctor was sent for who plugged the anterior nares, but then 
it came through his mouth. He says he lost two or three 
quarts of blood, which was of a very dark colour ; before the 
epistaxis he had vertigo and says he felt stupid. After this 
he was extremely weak, and was laid up for three weeks ; he 
had no more haemorrhage. He has had more or less cough 
ever since this time. Three months ago bis cough became 
more severe and his breathing diGScalt at night. Two months 
ago be had epistaxis again, in the night ; he had it every 
night for three weeks ; he says the attacks lasted about an 
hoar, during which time the bleeding was very profuse. He 
says he has sometimes bad pain in bis loins. He sweats a 
great deal at night, and his chief complaints are cough and 
weakness. On admission, he is a well-made man, about the 
ordinary height. He has an anxious expression. Skin 
intensely aufemic, hot, and moist ; lips veiy pale. Con- 
juQctiviD are a little jaundiced, there is well-marked sub-con- 
junctival cedema. No anasarca. His cough is very troable- 
Bome, and he expectorates much mucus but no blood. Breath, 
ing chiefly abdominal, resonance good all over, except for some 
impairment at right base behind ; expiration is rather pro- 
longed, and there are dry r&les all over right lung in ftont 
and behind. Impulse of heart cannot be felt. Precordial 
dulness very indistinct, it is almost entirely hidden by highly 
emphysematous lung. Heart sounds very distant, second 
sound rather accentuated ; no bruit audible. Radial artery 
H very tortuous, it is quite visible. Pulse 64, slow, persistent. 



Dig t,zec.y Google 



CAronie Bright't Disease without AUtumimirttt. S97 

and inoompresBible. Appetite fair, bowels usually regular. 
Liver dulaesB aeems to be decreased j it begins at fifth space 
and only extends two inches iu nipple line. Spleen not 
enlai^^ed. Urine normal in colour and quantity, acid reac- 
tion, sp. gr. 1026, no albumen nor sugar. December 6th.<— 
He complains of severe headache on left side of head. Dec. 
7th. — Head still very bad; he had a bad night. Dec. 9th. — 
Head better this morning ; he has had a slight epistaxis. 
Dec. 12th. — Headache continues; he has had some slight 
epiataxis during the night, which has relieved the head a 
little. After this be steadily improved up to the day of his 
discharge, on January 7th ; be still remained very anemic. 
His urine was always free from albumen ; the notes are as 
follows : 

Dec. 1.— No blbameii. 



During this time he was takiog Mistura Senegffi, and 
Chloral at night. 

Case 48. Severe epistaxit ; high arterial pressure ; hyper- 
trophy of heart ? urine normal. — John M — , set. 46. Dr. 
Goadhart (Clin, clerk, Mr. Strachan). March 22iid— April 
2nd, 1880. Patient has been a navvy all bis life, chiefly 
engaged in tunnelling on railroads. No history of hereditary 
disease. No previous illness of importance. He has lost bis 
sight for two years by cataract. Has been a free drinker 
both of spirits and beer. For the last two months he has 
found it necessary to get np several times during the night to 
empty his bladder. He was admitted on March 16th into 
the surgical wards for extremely severe epistaxis, for which, 
failing all other remedies, his posterior nares were eventually 
plugged. On the following day the ping was removed, aud 
this was followed shortly by another excessively severe hiemor- 
rhage, which necessitated further plugging, Thia being 
removed without recurrence, he was transferred to the medical 

! Google 



Sd8 CKronic Brlght'a Diseaie without Albuminuria. 

irards for further treatment. He ia an emaciated mim, of 
medioin height, and much blanched by the reoent loss of 
blood. The area of priecordial duloess is not increased; the 
apex beats in the fifih space, but nearly three inches below 
the nipple, " owing to apparent displacement of the latter 
(perhape from wasting}]" it ii situated in the nipple line. 
Itnpalse diffused over a rather large area. The firat sound is 
rather thick nod prolonged at apex, the second is accentuated 
at base and accompanied by an occasional creak. False 100, 
rapid, regular, short, persistent, not easily compressible. 
Artery Tcry hard, can be followed for some inches shore the 
wrist. All other physical signs were normal. His appetite 
had been poor for the last two or three weeks, and bis bowels 
confined. Urine acid^ of normal colour, no albumen nor sugar, 
sp. gr. 1024. Notwithstanding his recent severe hemorrhage 
and his aniemic and emaciated condition, the signs of increased 
nrterial pressure were so marked that Dr. Qoodhart did not 
fear to treat him for it; he accordingly prescribed Fulv. 
JalapK Co. jij, every morning. Mist. Rosse Laxativse ^, ter 
die, and Fil. Ferri Redacti gr. v, ter die. Full diet, without 
beflr. The result of this treatment was rapid improvement. 
March 23rd. — No further htemorrhage has occurred. Fatient 
feeli better. Temporal arteries are tortuous and very visible. 
Urine, sp. gr. 1032, no albumen. March 25th. — Feels stronger. 
Bowels have been opened three times. Urine 30 oz., sp, gr. 
1020, no albumen. Pulse quieter. March 2nb. — Continues 
better. False regular, 88. Heart sounds normal. April 
2ad. — Having been up several days, and feeling well, he left 
the hospital. Still no albumen in urine. 



VII. Cabbs with Vabiocs ManiCAL and Sdroical Diseases. 

Case 49. Disease tj/" knee-jomt ; resection ; amputation ; 
recurrent htemorrhage ; kypertrophied heart ; pericarditis ; 
granular kidneys ; transient albuminuria nfter eatheterism for 
stricture i death. — John M — , Kt. 68. Mr. Howse (Clin, 
clerk, Mr. L. E. Shaw). Admitted February 27th — Novem- 
ber 5th, 1880. He injured hia left knee-joint aix months 
before admissiou, and this becoming worse caused him to 

. , Google 



Chronic Bright'a Disease toiihout AUnminuria. 899 

apply at the hospital. He has drunk rather freely. Has 
had gonorrhoea more thao once, and saffere from a stricture, 
which has nerer been treated. At the time of admissiou it 
was noted that his apex beat was half an inch outside of 
nipple and rather pronounced ; the radial artery tortuoas and 
' very much thickened. Some difficulty occurred with his 
Btrictnre, and catheters were used for the first few days after 
admission ; the first note of the urine is on March 5th, it 
states that the urine contaiua some pus corpuscles and epithe- 
lium cells, sp. gr. 1080. March 8th.— Sp. gr. 10S0, very 
little albumen, no sugar. March 9tb. — Sp. gr. 1030, very 
little albumen, no sugar. The albumen on these occasions 
was probably due to the presence of pus, March lOtb. — Sp. 
gr. 1026, no albamen. After this there is no further note of 
the condition of the urine until April Sth. There is no note 
of any catheterisation after March 23nd, His knee-joint was 
excised on April 6th ; this was followed by a little oozing, but 
no hsemorrhage of importance. Id addition to recent suppn> 
ration, old osteo-artbritic changes were fuund in the joint. 
April Sth. — Urine sp. gr. 1025, acid, no albumen, no sugar. 
April 14th. — No albumen nor sngar. 

On April 17th it is stated that the pulse has been inter- 
mittent for tiTo days, in other respects he is doing well ; there 
is little or no fever; the pulse was normal again on the 20th, 
During July and August his general health appears to hare 
been fairly good, especially considering the severe local trouble. 
On September 21st some sinuses about the old wound were 
laid open, they were rather extensire. On October S^th it 
was discovered that there was a considerable amount of dead 
bone about the lower end of the femur } on November 2nd 
Mr. Howse amputated through the lower third of the femur. 
It is noted on this day that the urine does not contain 
albumen, sp, gr. 1024, Previous to the operation Dr, Good- 
hart examined the patient and failed to find any evidence of 
organic disease, the amputation was complete at 2.15 p.m. 
About 4 p,m. faiemorrhage from the stump was noticed ; it was 
discovered to come from the bone, and slightly also from the 
soft parts ; about a quart t£ blood was lost. On the night of 
November 4th he awoke restless and complaining of the pain 
in the stump; at 2 a.m, he had an injection of morphia (he 

logic 



4O0 Chronic Briffhft Disea$e vnthovl Al^unanuria. 

had frequently bad them before). He then fell asleep, but he 
breathed heavily all night and woke at 7 a.m. He was theo 
qaite sensible, but eomplsining of pain in the stump, breathing 
hearily and groaning. He died three boars afterwards. There 
was some question whether his death was not due to blood 
poisoning, and in relation to this it is noted that a patient in 
this ward had developed a serere attack of erysipelas ou 
October Slat, and was removed on November Snd ; another 
patient, set. 70, died on November 4th, from broncbo-pneu- 
monia after an operation for strangulated hernia. 

Pott mortem (by myself). — A well-formed, but rather 
emaciated body, liiin old adhesions scattered all over both 
pleune. Rather firm matting about region of pericardium. 
Lungs coarse and somewhat emphysematous; tnbea contained 
frothy secretion. Both layers of the pericardium were covered 
completely by a thick layer of lymph, with the usual shaggy 
surface ; this could be stripped off the heart, and was about ^th 
of an inch in thickness. Heart-19 oz. ; the muscle was fairly 
good, except the part immediately below the pericardium, here 
the muscle was pale and apparently fatty; left auricle slightly 
thickened ; left ventricle considerably hypertrophied ; aortic 
and mitral valves thick and opaque, otheririse normal ; right 
side normal ; a little atheroma in the aorta. Arteries gener^ly 
thickened. The abdominal viscera were all normal. Liver 
64 oz. ; spleen 7^ oz. Kidneys 8J oz. ; both organs were 
rather small, the capsules peeled fairly well, but the structure 
was exceedingly indistinct and "muddled" looking; cortex 
atrophied somenhat ; vessels decidedly thickened. The micro- 
scopical appearances of the kidney are exhibited in Plate II, 
which was taken from this specimen; it shows slight inter- 
stitial thickening, more especially due to the thickening of the 
membrana propria of the tubules ; the capsules of the Mal- 
pighian glomerules were also distinctly thickened, and some of 
the tufts were atrophied and more or less obliterated; there 
was decided thickening of the muscular coat, and some of the 
intima of the arterioles ; the epithelium is granular and exces- 
sive in amount; some of the tubes contain casts. Testes 
healthy. 

Case 60. Aneurism of popliteal i ligature of femoral ; hyper- 



Chronic Brighi's DUeane without AUntminuria. 401 

trophy of heart; normal urine; subsequent acute nephritis 
during conBoleacenee ; death. — Elias W — , let. 42. Admitted 
November X7th, 1880; died February 17th, 1881. Under 
Mr. Bryant. Suffering from aneuriam of popliteal artery. 
He baa previously had fairly good health. He had no albu- 
minuria at the time of admisMon. His niieurism was treated 
by compression, which failed, and then by ligature, which 
cured it. No geaeral signs of vascular disease were detected 
during his lifetime. His urine was very frequently examined ; 
it wu generally of small quantity and high sp. gr,, owing to 
restrictions in the quantity of fluid diet. It was always free 
from albumen until January lOtb, 1881. He was conva- 
lescent and about to get up when he developed an attack of 
acute renal dropsy, and died in about fire weeks. Hia urine 
was tested several times before the operation, and waa always 
perfectly normal. 

Past mortem (by Dr. Hilton Fagge). — The kidneys weighed 
14^ oz. ; they were blurred, greyish, and slightly yellow. 
Heart weighed 14 oz. ; left ventricle dilated and hypertropbied ; 
in the pericardium there waa 16 oz. of clear, straw-coloured 
fluid. A considerable quantity of fluid in the pleurie. Lungs 
small, nearly airless, oedematous ; liver 54| oz., indurated, pale, 
and somewhat faity; spleen 7 oz., firm. 

Case 61. Multiple cyaticerei cellulose ; high arterial pro- 
ture ; urine normal ; hypertrophied heart ; granular kidneys ; 
death. — Mary 8—, et. 64. Dr. Hahershoa (Clin, clerk, 
Mr. R. T. Jones). March 12th; died April 23rd, 1879. 
A charwoman, has had winter cough three years, and recently 
cedema of the legs. Admitted with signs of bronchitis, yellow 
conjunctiva, and prolongation downwards of the edge of the 
liver. As she was aniemic and wasted, cancer of the liver was 
suspected, and it was thought that the existence of malignant 
disease was confirmed by the discovery of numerona small 
nodules under the skin of the arms, chest, and back. Tliey 
were not adherent to the skin. The urine was of guud 
specific gravity (1018], and contained no albumen, hut the 
pnlse was persistent and long, and led me to the diagnosis of 
Bright's disease. , 

Post mortem (by Dr. Hilton Fugge). — A remarkable case of 
VOL. XXV. Xft-- I 



402 Chronic Bright'a Diaeaae without Alhuminuna. 

multiple Cfsticerct celliilosfe ia the subcataneouB tissaes, the 
heart, aod the braia; the details of this conditioa miif be 
omitted here, as thej have no bearing on the condition of her 
heart and kidneys. In the cerebellum there was alight but 
estensive capillary apoplexy, no doubt a result of the granular 
condition of the kidneys ; no cysticerci were present in this part 
of the brain. Lungs very emphysematous indeed, and highly 
(edematous; much purulent mucus in tubes. Heart 12 oz. ; 
mitral valve rather thick edge; some arteritis deformans. 
Liver and spleen healthy. Kidneys 9 oz., graoalar, rather 
pale, with wasted cortex and large hilus. 

Case 52. — Sciatica ; hypertrophied heart; high arterial 
pressure ; urine normal. — ^William K — , »t. 72, Dr. Mozoa 
(Clin, clerk, Mr. Dowbod). Admitted September 7th — dis- 
charged October 27th, 1880. His family history was good. 
He has been employed for the last thirty years in a brewery, 
and has during this period drunk beer freely. When 18 years 
of age he had an attack of rheumatic fever. He bad sciatica 
for the first time rather more than ten years ago ; he was 
then in this hospital twice for this disease ; the last time 
he had lumbago as well, and for this he was cupped over the 
loins, of which he still bears the marks. He has had no 
severe attacks for ten years, but has had occasional darting 
pains down the right leg. For some months he has suffered 
from headache and slight sickness in the early part of the 
day. He was admitted with severe and very typical sciatica, 
of which I need not give any further account. He is a dull, 
heavy. looking man, rather autemic, his akin having a yellowish 
tinge. He has several sebaceous tumours about bis body. 
His hair and eyebrows are very coarse and turning grey. 
There is no oedema. He has slight bronchitis and rhonchi 
are audible in the larger tubes. The apex of the heart beat* 
in the sixth space half an inch external to the nipple line. The 
heart sounds are indistinct ; the first is scarcely audible at 
base, but the second is accentuated. The cardiac dnlness is 
increased. Pulse very long and peraisteut, but the artery is 
little if at all thickened. His sciatica was tnnch relieved by 
treatment ; in other respects he went out as .he came in. His 
urine was very carefully watched throughout, and the table 



Co(.H^Ic 



Chronic Brighl't Disease mthout Albaminwia. 



403 

appended shows its uniformly normal quality and quantity. 
It was invariably acid and free from albumen, for which it was 
tested daily. Uric acid crystals were present in it on two 
occasions. 



»2m. 


1020 


62 „ 


1018 


32 ,. 


1022 


68.. 


— 


60„ 


1014 


80„ 


1010 


68 „ 


1010 


68 „ 


1010 


64 „ 


1010 


66 „ 


1012 


40 „ 


— 


40 „ 


1011 


«8„ 


1012 


66., 


1014 


40 „ 


1020 


40„ 


1018 


60„ 


loia 






62 „ 


1012 


48 „ 


1012 


40 „ 


1020 


60 „ 


1012 


40 „ 


loia 


82 ,. 


1012 



1010 
1016 

1012 
1014 
1010 



oy Google 



404 Chronic Bright'a Dueate without Albttmumria, 

Vf. QiuBtiljr. Sp.(r. SoUdi. 

Oct. 10 ... li ox. ... loea ... 1144 

n ... 68 „ ... 1010 ... 6S0 

2> ... 48 „ ... 1014 ... 678 

SS .,. 40 „ ... 1012 ... 4S0 

M ... — ... — ... — 

SC ... 48 „ ... lOlS ... GTS 

Ml ... 40 „ ... 1018 ... 7S0 

» ... — ... 1018 ... — 

Cjui 68. — Paralytit agitaiu ; hyperirophied heart ; high 
arterial pretmre; normal urine. — Eleaoor P — , let. 71. Dr. 
WilkB (Clin, clerk, Mr. Pizey). March 10th— April 20th, 
1880. A washerwomBD . Father died at 74, of "old age," 
Mother was subject to fita, and died in one, at the age of 70. 
One brother died of consumption, and a sister had a fit and 
died five weeks after it, haring lost her speech and the use of 
the right side of the body. She has been in the hospital with 
erysipelas, but she forgets when. She had what she calls 
" rheumatism " some years ago, which has left some of the 
finger-joiota in each hand enlarged (gout F). Has always 
been a very nervous woman. Has been temperate. She is a 
rather short old woman, with white hair and eyebrows and 
dark eyes. She has paralysis agitans affecting the right arm 
only. The apex of her heart is much displaced outwards, the 
second sound is accentuated. The poUe is very hard and 
persistent, the artery Tery thick. Urine pale in colour, sp. 
gr. 1020, acid, no albumen. On March 18th, 88 os. were 
SRTed, sp. gr. 1020, no albumen. She had a prolapsus uteri, 
and with it some difficulty in holding her water ; it waa there> 
fore fouud impossible to save and measure it. Further notes 
of the urine are made ou March 19tb and 23rd; on both 
occasions it was normal. 

Casi 54. AlcohotUm; vertigo ; high arterial pressure ; albu. 
minwritt foretold and transient. — Robert Q — , st. 40. Dr. 
Moxou (Clin, clerkf Mr. Bothamley). January 22Dd — 
March 8th, 1879. A lighterman. Father and mother said 
to be rheumatic ; latter died of heart disease. Patient had 
rheumatic fever two years ago ; frequently has pain in the 
joints. Syphilis with ■econdaries seventeen years ago. Was 



„Gooj^Ic 



Chronic Brighl't Digeate without Albuminuria. 406 

in Philip Vfaxd with pleurisy a year ago. Has been in the 
habit of taking seven or eight pints of beer each day, besides 
spirits occasionally. He had a sudden attack of veriigo 
fifteen days ago, with some sickness at the onset; the giddi< 
has remained ever since and his gait has been staggering. He 
is a dark, healthy-looking, well-nourished man, with a some- 
what dull expression. Lower eyelid rather puffy. His 
appetite is bad, and he is sometimes sick in the morning and 
always baa nausea. He still has a rather uncertain stagger- 
ing gait and complains of giddiness. There is no further 
note of the condition of his nervous system, bat he was 
considered by Dr. Moxon to be suffering from alcoholism, 
and he gave no evidence of organic disease. " OphthaU 
moseopical examination. — No retinal hERmorrhages. Discs 
normal." His apex beat is in fifth interspace, internal to 
nipple. There is no thrill or bruit. I made a note that 
"his pulse was extremely hard, persistent, and long; his 
second sound is accentuated intensely ; his arterial tension is 
extremely high." 



Respiratory system normal. Urine pale in colour, clear 
acid reaction, sp. gr. 1015, no albumen, sugary or blood, The 
arterial tensioo in this case was so high that - 1 remarked to 
the clerks that in such a condition it probably only required a 
little exposure to cold to cause albumen to appear in the 
urioe, a prophecy which was shortly verified. His urine was 
examined almost daily, and found free from albumen. A 
special note to this effect occurs on January 28tb, 29th, SOtb, 
Febrnary Ist, 2od, 3rd, and 4tb. On February 5th the follow- 
ing note occurs : — " A very slight trace of albumen is present 
in the urine. He was out in the park yesterday." The 
weather was raw and cold just then. On February 6tb and 
7th there was still a little albumen. February 8tb, — The 
albumen has completely disappeared again. It was never 
found again daring bis stay in hospital, though constantly 

Google 



406 Chronic Bright't Disease without Atbumitmria. 

watched for. He went out on March 7tfa. He has not the 
least UQsteadineu of gait now and very seldom feels giddy. 

Case 55. Dy^pria ; hypertrophied heart; high arterial 
pressure ; onee a trace of albumen. — Eliiabeth I — , set. 57. 
Dr. Wilks (Clin, clerk, Mr. Jackson). July 15th— August 
9th, 1880. Has had several severe illnesses, the nature of 
which seetnB obscure ; she is said to have had rheumatic fever 
three times. She comes in for swelling of the ahdomea 
and flatulence. She says that her feet have heen swollen, 
and that her face is occasionally puffy ; they were not 
so at time of admisaion. Heart's apex displaced much 
outwards, impulse forcihle and heaving in sixth interspace, 
about one inch or more external to nipple line ; second 
sound in aortic area very intense. No hmit. Pulse very- 
persistent, long, and pushing. Artery thickened. Urine 
Bp. gr. 1020, no albumen. July Slst. — Complains of pain in 
loins. Urine very pale in colour, sp. gr. 1010, a trace of 
albumen. July 81st, — Urine sp. gr. 1010, very pale straw 
colour, no albumen, slight quantity of phosphates. The 
report fails to give anything like a complete record of the 
urine. I believe it was tested more frequently and found 
free from albumen on all occasions. 

Case 56. Severe recurrent attacks of vomilinff and pyrosis; 
high arterial pressure ; temporary aortic regurgitation or peri- 
carditis ; vrine normal. — Mary P — , let. 42. Dr. Pavy (Clin, 
clerk, Mr. E. Starling). April 16th, 1879. At intervals till 
May 2tid, 1880. She had good health till three or four years 
ago, when she was attacked with nausea and vomiting of a 
clear fluid, sometimes acrid, at others tasteless ; sometiiues she 
would bring up very little, at others as much as half a pint. 
These attacks would sometimes last for several weeks and then 
leave her. During the attacks even the sight of food would 
cause nausea. Says she has lived principally on bread aad 
cocoa. On admission she was quite unable to take food, fre- 
quently vomiting a clear fluid of alkaline reaction 'containing 
abundance of Torula cerevisise; has a cold, numb sensation at 
the epigastrium, aod pain up the oesophagus. The precordial 
duloesB extended from fourth spsce to apex in sixth space, and 



„ Google 



Chronic BrigfU'i Diseate withoul Al&wninuria. 407 

from middle line of sternum to just internal to nipple. Apex 
beat can be felt but not seen in sixth space, about one inch 
internal to nipple. First sound clacking, second sound loud 
and accentuated. Pulse very long and pushing, artery thick- 
ened. The sphygmograpfa showed the pulse to be one of 
exceedingly high pressure, the cardiac systole being much pro- 
longed. 



Taken with Pond'i iphjinogivpta. PreHnre not rscorded. 

There vas sabconjunctival oedema but none elsewhere. 
Urine of uormsl colour, ap. gr. 1024, no albumen, sugar or 
bile, contaius indicRQ, a mucous cloud, do casta. She seems 
to clip her words somewhat, there is slight external stra- 
bismus of right eye. She continued constantly vomiting clear 
fluid and suffering much from heartburn, taking nothing 
but a little milk and lime water. April 17th.' — Last night 
vomited a little clear alkaline fluid with abundance of tonila. 
April 19tfa. — Last night vomited about a pint of dark greenish 
coloured viscid fluid of acid reaction, showing under the 
microscope fat globules aud tornla. April Slst. — Dr. Favy 
called attention to the frequent sighing and the external stra- 
bismus, with the nausea and vomiting on an empty stomach. 
He says that there may be some cerebral mischief. April 
24th. — Patient says that she felt as if something burst in her 
throat last night ; she then felt better! April 25th. — Is much 
better to-day, she feels as if she could eat an egg, hitherto 
having ouly taken milk and Liq. Calcts. May 5th. — Has had 
meat for fonr days and has bad no nausea or vomiting since 
April 25th; feels and looks much better. May 11th. — Left, 
apparently quite well. Readmitted on Oct. 16th, 1879. Her 
illness was merely a repetition of that which she suffered in 
April. Her pulse was still one of high pressure. On exam- 
ining the heart a to-and-fro bruit was heard down the sternum 
and most distinct a little to the left of the lower part of this 
bone. There is no note of any displaceraeut of the impulse of the 
heart, and I cannot remember that any was found. October 
18th. — The vomiting still persists. There is a little ptosis of 



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408 Chronic Bri^hfa Diteaae without Albuminuria. 

left lid. Optic discs examined and found to be normal. On 
October 23rd the icmiting had ceased. Go NoTember 2nd 
the TOTniting again returned j on the 8th she had diarrhoea. 
Not. 10th. — Diarrhoea haa continued and patient looks very 
weak. Vomiting haa increased very much. She states that 
the presence of food in the stomach does not cause pain and 
that the yomitiag is generally worse vben the food is absent. 
November 15th. — She is a little better and does not vomit aa 
much as she did. Vomiting is not excited or increased after 
food. November 29th,-^She was discharged to-day, having 
steadily improved. There has been no returii pf the vomiting. 
The bruit can be heard but is very indistinct. Her urine was 
carefully watched during her stay in the hospital. The obser- 
vations are recorded in the following table : 

Dila. QouIitT. 8p. |r. SolidL Ub. 

Oct 29 ... 88 oi. ... lots ... 608 ... None. 

80 ... 48 1018 ... 616 

81 ... 40 „ ... lOiO ... SCO ... 
Nov. 8 ... 88,. ... — ... — ... 

4 ... 40 „ ... 1025 ... 1000 ... 

6 ... 84 1018 ... 612 ... „ 

6 ... 84 „ ... 1018 ... 612 ... „ 



1023 
1022 
1020 

1024 
1026 
1020 



Beadmitted March 20th, 1880. — Her symptoms were the 
aame aa before, the attack was not quite so severe. On ad- 
mission I have noted that the to-and-fro aortic bruit pre 

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Chronic Brighl't Disease mth Albuminuria. 409 

Tionsl; audible could not now be detected. I never he»rd it 
during ber stay on this occasion. Her pulse was still one of 
high pressure and the second sound was accentuated. It was 
noted at the time of her admission on this occasion that her 
urine contained albumen, amorphous urates, and phosphates. I 
doubt whether much reliance can be placed on this observa- 
tion ; the report is a very imperfect one, no further note of 
albumen is made, and it is said to be absent at the time of her 
discharge. I think that a cloud of phosphates produced by 
heat was mistHken for albumen. She was discharged well ou 
May 2nd, 1880. 

Cask 67. Strangulated hernia ; operation ; great hyper- 
trophy of heart ; thickening of arteries ; fairly good kidneys ; 
death. — Francis H — , set. 60. Mr. Howse (Cliu. clerk, Mr. 
Kichardson). March I6thj died March 18th, 1880. Ha 
was admitted for hernia, which had been down tbirty-six 
hours ; an operation was performed on the night of admission, 
and he died two days afterwardB. Hia son says that he bad 
always had good health ; be never remembers him ill before. 

Post mortem (by Dr. Hilton Fagge). — After describing the 
local conditions of the bowel and peritoneum, the repott con- 
tinues : " The heart was much hypertrophied, weighing 18^ 
OS., the left ventriclB being extremely thick, but also the left 
auricle. Valves all healthy. The kidneys appeared healthy, 
but the arteries in them were thickened. The microscope 
showed that there was some degeneration of certain Malpighian 
tufts, and perhaps a little excess of stroma in the kidney, but 
their structure was prsctically healthy. The arterioles of the 
pia mater showed moderate thickening, chiefly of the muscular 
coat. / t/iink the case is distinctly opposed to ike view that 
cardiac hypertrophy is secondary to an advanced degree of 
kidney disease." 

VIII. Cases of Typical -CHaoNic Brioht's Disease, kith 

WELL-HAKEBD ALBrMlNUKIA, WHICH WAS VARIABLB OB 
DIBAFFBARED WUILB VNDEK TrEATHB.NT. 

Case 68. The third attack of dropsy and albuminuria, both 
of which disappeared under treatment ; high arterial pressure ; 
hypertrophy of heart f urine became normal, — Bridget K — , 



410 Chronic Brighfs Diteate with Albuminuria. 

let. 42. Dr. Hilton Fagge (Clin, clerk, Mr. L. K. Stepbens). 
Not. 27th, 1880 — Feb. 23rd, 1881. She hnd worked fur 
many years as a cleaner in the hospital. Admitted for general 
veakneas and dropsy. Father died set. 42 of coosumption, also 
mother, set. 52. Has had seven brothers and sisters, of whom 
three died of consumption. Patient had general dropsy when 
IS years of age, again during a pregnancy when 28 years old, 
not again till preaeut attack, which commenced in tbe summer 
of this year. For about sis weeks she has perspired much at 
night, her night dress and hair being quite wet through in the 
morniog. She has been out of sorts all the summer, com- 
plaining chiefly of " swimming in the head," paffiness under 
eyes in the morning, also of the bauds and feet. Thinks that 
lat«Iy she has passed less urine than usual. She is a well- 
nourished woman, with a care-worn anxious ezpression, is 
sitting propped np by pillows, as she says her back feels very 
sore when she lies down. No mdema of feet, legs, or hands, 
slight puffinesa of lower eyelids. There is considerable oedema 
in the lumbar region ; if she gets out of bed and sits for a 
quarter of an hour, her feet begin to swell and get stiff, which 
swelling almost as quickly subsides on her return to bed. 
Cardiac impulse regular and strong, apex beat in 5th inter- 
space, two inches from middle of sternum, in nipple line. 
Area of cardiac dulness not increased. There is accentuation 
of second sound and long first sound at apex. No murmurs. 
Pulse 66, regular, long, full, and compressible. Tracing 
shows exceedingly high arterial pressure. 



Tongue flabby and tremulous. Appetite bad, cannot eat 
anything iu the morning; she has not beeo able to do so for 
two or three years. Bowels confined for four days. Lung 
signs normal. She has had almost const snt right-sided head- 
ache for the last three months. The urine when admitted 
contained about " half albumen." For several days she con- 
tinued much in tbe same condition. Dec. 15tb. — She feels 
better and has lost the severe headache ; alie ut up for an 



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Chronic BrighVi Ditease wUk Albuminuria. 



411 



hour last oight ; this morning there is oedema of the feet and 
legs ; the abdomen is distended hy fluid and measures 36 iucfaes 
in circumfereDce at the level of the nmhilicus. On Dec. 18th 
she was ordered Tr. Ferri Perchlor. v\\v, Sp. Cblorar. mx. 
Inf. Digitalis ,^, Aq. ^, ter die and under this treatment, 
aided by Fulv. Jalapie Co. 9ij at night occasionally, she 
rapidly improved] the quantity of urine increasing, and tlie 
amount of albumen steadily decreasing, tilt it shortly after- 
wards disappeared entirely. On Dec. 17th the urine con- 
tained one-tbird albumen, by the 22ud it was reduced to " a 
trace," and on the 30th there was none. On the ZSrd the 
circumference of the abdomen had fallen to 30j, and by Jan; 
13th it had reached and remained permanently at SSJ inches. 
She went out on Feb. 23rd, her urine haYing afforded for con- 
siderably over two months not the least indication of renal 
disease ; this could only have been suspected from the per- 
sistent high pressure, the slight displacement of the apex 
beat, and the history. 

Due. (tuntllr. Sp. tr. SoUdi. Alb. Binrdi. 

Decl ... £6oi. ... 1026 ... 650 ... 



1024 


720 


i 


1026 


780 


i 


loia 


90O 


i 


1012 . 


&8S 


i 


1014 . 


. 672 


k 


1014 . 


938 


i 


1013 


. 1278 


. Tnce 


loia . 


. 1020 


. Sono 


1010 


740 


« 



,Google 



412 Chronic Bright'a IH*ea$e with Albuminuria. 



e7oi. . 


. 1010 


60„ . 


, 1012 


62 „ . 


1014 


70 „ . 


1014 


fiZ .. . 


. 1018 


68 „ . 


1016 


83 „ . 


loao 


S3 , . 


1020 


35 „ . 


. 1018 


42 u ■ 


1018 


61 „ . 


1012 


63 „ . 


. 1016 


66 „ . 


1012 


60 „ , 


. 1018 


60 , . 


— 


67 „ . 


1015 


36 „ . 


1018 


4i . . 


. 1016 


43 „ . 


. 1016 


43 . . 


1018 


67 H . 


. 1016 


66 „ . 


. 1016 


40 „ . 


1018 


40 „ . 


. 1018 


60,. . 


1012 


49 „ . 


. 1012 


48 „ . 


. 1012 


40 „ . 


. 1004 


34. . 


. 1012 


46 „ . 


. 1013 


44„ . 


1012 


44 „ . 


. loia 


68„ . 


1014 


72 „ . 


1014 


86 „ . 


. 1014 


48 „ . 


, 1012 


M„ . 


. 1018 


82 „ . 


1014 


62 . . 


. 1012 


63 » ■ 


. loia 


48 „ . 


. 1018 


36„ . 


1013 


62 >. - 


. 1012 


66 „ . 


. 1012 


64 „ . 


. 1014 


60. . 


. 1012 


46 „ . 


1012 



I.C, Google 



C&ronic Bright* m Ditease with Albuminuria. 418 

DiU. ftnuiUljf. Sp. p. Solldi. Aft, Boatli. 

F«b. 11 ... 60 «. ... 1012 ... 710 ... None ... % 

la .., 40 „ ... lOia ... 480 1 

18 ... 48 ,. ... 1018 ... 676 ... „ ... 

14 ... 40 „ ... 1014 ... 660 ... „ ... 1 

16 ... 40 „ ... 1012 ... 480 ... „ ... 1 

16 ... 8S „ ... 1012 ... 48S ... „ ... 

17 ... 4$ „ ... 1010 ... 460 ... „ ... 1 

18 ... «0 „ ... lOia ... 720 ... „ ... 1 

19 ... 40 „ ... 1012 ... 480 ... „ ... 1 

20 ... 68 „ ... 1012 ... 673 ... „ ... 

21 ... 42 „ ... 1012 ... 604 ... „ ... 1 

22 ... 44 , ... 1012 ... 628 1 

Casi 59. Typical Bright'a diaeate ; hypertroplued heart ; 
retinal hiemorrhagta ; albaminvria ; temporary diaappearance 
of albumen. — Sophia Sanger, et. 57. Dr. Pye-Smith (Clin. 
clerk> Mr. Jackson). Angnst 11th — September 2lBt, 1880. 
Her father w&s subjecC to rbeumatio gout. She haa always 
had good health until about a year ago, when she began to 
lose her sight — she found she was anable to thread her needle. 
She applied to aa ophthalmic hospital, where she was told 
that glasses would be of no use to her. She is unable to dis- 
tinguish the face of auy one standing close to her. Passes a 
good deal of urine in small quantities and frequently. Com- 
plftioB of pains iu the back and loins, and of nausea in the 
morning. She is a thin, annmic woman. There is a little 
csdema about the left ankle, none elsewhere. Apex beat in 
6th space, about one inch external to nipple. The heart ia 
not regular, missing a beat now and then. There is a systolic 
bruit beard at apex and in axilla, but not in the back. There 
is also a systolic bruit audible at base and in the neck. The 
second sound is accentuated. Pulse persistent and incom- 
pressible, the artery rery much thickened and arterial pressure 
extremely high. Lungs said to be normal. Passes a fairly 
large quantity of pale straw-coloared urine, opaque and cloudy, 
Bp. gr. 1009. Albumen present in considerable quantity. 
The eyes were examined by Mr. Higgens on Augnst 22nd. 
Right eye, glistening white patches and spots in retina, espe- 
cially about yellow spot. One rather large branch of vessel 
in right eye looks like a white cord ; it appears obliterated or 
surrounded by an opaque material. On August IStb, 14tb, 



DigtizedoyGOOglf 



414 C/trortu: Bright'$ Dueaae with Albuminuria. 

and I6th albumen was present in the urine, but in decreasing 
amount, ap. gr. ranging from 1007 to 1015. Ou August 17tb, 
18tfa, 19th, no albumen could be detected in the urine, sp. 
gr, each day 1010. August 21at. — A very small amount of 
albumen present, August 33rd, 24th and S5th. — No albumen 
could be found. After the last date it reappesred, and con- 
tinued present in large quantity (about J) until she was dis- 
charged. The sp. gr, Taried between the limits mentioned 
abore. 

Case 60. Acute attack of Bright't disease at 60 ; dilated 
heart ; mitral regurgitation ; albuminuria, which con^letely 
ditappeared, — Charles B — , tet. 60. Dr. Pavy (Clin, clerk, 
Mr. Darid). June 10th — October 6th, 1879. A coachmao 
and gardener. Family history unknown. Last September 
(nine months ago) he caught "a severe cold," and was laid 
up in bed till ChriBtmai time. He has been up once or 
twice since for a short time, but always relapsed; recently 
his cough has been very bad, and hia sputa streaked with blood. 
He aits up in bed looking distressed and breathing with diffi- 
culty; his conjunctirffi are slightly JHundiced and cedematons. 
Cheeks have a bright colour from dilated venules. Fingers 
clubbed and nails carved. Impaired expansion of chest; 
general signs of bronchitis, with dulness at right base behind, 
and moist r&les most abundant in this area. Cardiac dulness 
is said to be normal ; the impulse of the heart cannot be felt. 
Heart sounds very faint, irregular rhythm, occasional systolic 
bruit. Pulse 60, irregular, bard, and incompressible. Urine 
slightly high-coloured, sp, gr. 1018, albumen abundant. 
He continued in much the same state till June 30th, when 
it is noted that his urine contained "no albumeD." July 
1st. — He baa passed four pints of urine in last twen^-four 
hours. On the 3rd albumen has agaiu appeared. July dth. 
— Heart's action very irregular, tumultuous, and rapid. July 
11th. — There is dulness over the bases of both lungs, and 
moist sounds are audible here. July lOtfa. — It is noted that 
a loud bruit is heard at the apex. July 81st. — Patient looks 
very ill. Conjunctivte yellowish j breathing troublesome ; 
abdomen swollen, and appears to contain fluid ; liver en- 
larged. Passes only about three-quarters c^ a pint of urine 



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Chronic Bright'* Diaeaae mth Albwnitmria. 415 

daily, high coloured, Bp. gr. 1026, albumiaons. Bruit 
heard as before. August 8th. — Patient contiaues verjr ill. 
Urine getting rather more abundant, a piat and a half in 
twenty-four hours, ap. gr. 1020. Moist sounds over both 
bases, extending to within two inches of spines of scapulee. 
Bruit not so loud. About the beginning of September the 
patient commenced to improve. On September 12th he is 
feeling much stronger. Albumen very much leas, only about 
one-sixth. He gets up now of an afternoon. September 14lh. 
— Still improving, he gets up every day. No albumen in 
urine, bat some deposit of urates. September 26tb, 29th, and 
October Sth. — Each day he is said to be improving, and his 
urine is found to be normal. He went out on the latter day, 
bis breathing much relieved. 

Caab 61. Acute renal dropty, probably chronic dUtate ; 
blood and albumm variably present, their pretence determined 
by leaving the bed. — Charles V — , let. H. Dr. Habershon 
(Clin, clerk, Mr. S. Thomas). February 10th — April 7th, 
1879. A labourer. Has been a great drinker, chiefly of 
spirits. Family history unknown. He has bad smallpox, 
famine fever, and ague. Was in Ouy's under Dr. Owen 
Bees eleven years ago with pleuro-pnenmonia. He suffered 
from stricture of the uretbra fourteen years ago. He has 
been subject to cough every winter for the last eleven years. 
He has been in the habit of weighing himself daily, his ordi- 
nary weight varying between 9 at. 12 lbs. and 10 st. j three 
weeks ago he waa aatonisfaed to find himself 10 st, 9 lbs. j he 
had been getting heavier for four days. Two days after this 
he noticed that his face and the back of his hands were enor- 
mously swollen, and that when washing himself his abdomen 
shook about; he also passed very little urine, and what he 
passed was of very high colour. He came up to the out- 
patients', and after a week's treatment was recommended for 
admission. He is a pale, fairly nourished roan, his face is 
pnSy, and his feet and legs oedematoua. Liver one inch 
below ribs. Abdomen flaccid. Chest barrel-shaped, hyper- 
resonant, especially at led apex, where there are some moist 
sounds audible. Area of cardiac dulness rather increased. 
Apex beat detected with difficulty, it appears (o be in 6th 

. „Gooj^Ic 



416 Chronic Bright* Dueau teith AUmminKria. 

■pace Knd a little internal to mKinniEir^ line. Second sound 
accentufited. Pulse very persistent and cord-like, long and 
incompressible. Urine small in quantity, pale straw-colour, 
sp. gr. 1012, contains a smnll quantity of albumen, la four 
days the oedema had completely disappeared frum the legs. 
The patient steadily improved. On March 7th the albumeo 
had completely disappeared from the urine. It remained 
absent on March lltb. On the 17th a trace of albtimen, and 
also of blood, had appeared in the urine, sp. gr. 1025. Ou 
the 24th and 25th the urine contained no albumen, but gave a 
slight reaction with the guaiacura test. Again a trace od 
the 26th, much on the 31st, but neither albumen nor blood ou 
April 4th. It bad reappeared again on April 7tb, when he 
was dischai^ed. This variation is no more than is commonly 
seen in the albuminuria following scarlatina, and in this case 
it was determined, as it often is in the scarlatinal cases, by 
leaving the bed ; he was free while he stayed in bed, whereas 
he had albuminuria on getting up and going out. In scar- 
latinal convalescents I have repeatedly watched this change 
from normal to albuminous urine ; half an hour out of bed is 
often long enough to produce it. The rapidity of this change 
is too great for the kidney condition determining it to be a 
structural one; it must be functional, or mure probably a 
vascular phenomenon. The fact stands, therefore, that the 
game kidney, and that a diseased one, can produce alike normal 
and atSuminout urine. 

DESCRIPTION OP PLATES. 

(From dnwing* hj Mr. Obor»i Tdbitzb.) 

ThcH Platsi KTe intended to ihoir different degree! of tliB TuoaUr end inter- 
ititiHl changee which ire prodaced In kidneji lubjaeted to the inflnenca of 
prolonged high arterial preasare, teitiouf nephritii. 

Plate I >lu>w) the chuDgea in B well marked degree; Plate II ahowi tlie ume 
change* in a maeh earlier itag«. 

The change* preient in mj ■peciinen* are ai fbllnm : — The mtmlrwia propria 
of the tuhulei ia thickened MCh in the eortui and in the medalla ; thurv i> alao 
inter-tahular Gbro-hjiline thickening. 

There U a limUiu- liyaline thickening of the iafuaa of the artcriiw, •ometimea 
of the advtHtiiia. There U thickening of tha miuciilar coat of the amaller 

There ii flhra-hjaline thickening of the eapanln of tbe Malfnghian tnfta. 
Involving tbe >e*arlii of tbe glomtru/i, and in wnie oue* obliterating them. 
'" ' iiible in the ipecimeni. 



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D„t,M,Google 



D„t,i.a,Google 



ON A REMARKABLE INSTANCE 

HEREDITABY TENDENCY 

PRODUCTION OF SUPERNUMERARY DIGITS. 



bt e. clement lfcas, b.s. 



T&E irresiBtible tendency of the offspring to resemble their 
parents is ho well recognised that it is a divarication from the 
Qrpe rather than a resemblance which is apt to excite com- 
ment. The height, the build, the features, the complexion, 
the constitution, are all traceable to one or other parent, as 
well aa such minor details as the size and direction of the 
teeth, the shape of the nails, the growth of hair and the time 
at which it may decline. 

Certain mental attributes are scarcely less obvioasly here- 
ditary. Galton has collected many interesting facta in support 
of the belief that genius is hereditary, and specialists in mental 
diseases are not lacking in proof that lunacy is transmitted 
from geueration to generation. The hereditary tendency to 
certain diseases is fiiUy recognised, but the recurrence of 
deformities in successive generations has, perhaps, excited lees 
interest and received less attention than it deserves. Among 
minor deformities I have more than once traced a crooked 
tittle finger through three generations. It is seldom that one 
meets with so intelligent a parent and one so well acquainted 

™' •"■ " Google 



418 Hereditary tendency to the 

witli his family history ob the man vho furnished the accom- 
paaying genealogical table. For the details of the history 
and the strikingly clear manner in which the pedigree is 
shown, I am indebted to my dressers, Mr, Key and Mr. 
Kichardson. The liability to the production of supernumerary 
digits vas well known in the family to which this man 
belonged, and when an infant was added to his family his 
first thought was to examine its feet and hands. 

I am made aware through the prospectus of lectures given 
at the Royal College of Surgeons that Mr. Hutchinson 
delivered this spring lectures on heredity in which attention is 
drawn to this abnormal development, but I was prevented 
from attending these lectures, and as they have not yet been 
published I am nnable to allude to the results of his ofaser- 
vations. 

It will be seen on referring to the chart that supernumerary 
fingers and toes can be traced in this family through five 
generations. It was transmitted through the maternal great 
grandmother, the grandmother, and mother to the man who 
furnished the history, and whose children were brought under 
my observation. Altogether the great grandmother of my 
patients appears to be responsible for abnormalities occurring 
in no less than twenty-four persons out of a total of eighty 
descendants, or thirty per cent, of those carrying her blood. 
Considering the number of times the blood has been diluted 
by marriage, the persistency with which this tendency asserts 
itself is very remarkable. The maternal grandmother had a 
family of eight, five of whom were afiected, viz., two sons and 
three daughters. Her eldest son, though himself normal, bad 
three children afTected out of a total of oine. The second son, 
who was over six feet in height and had six toes on each foot, 
had seven children, three of whom were affected. The third 
son escaped, and his famUy of seven also escaped. The fourth 
son, in addition to six toes on each foot, was the subject of 
harelip; he had no family. The eldest daughter had six toes 
on each foot. She had four sons and a daughter. Two sons, 
the first and the fourth, had extra toes, whilst the second and 
third sons and the daughter, who was last bora, escaped. The 
second daughter had an extra finger on each hand. She had 
a family of ten, six sons and four daughtera, of whom two only 

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Production of Supernumerary IHgita. 419 

vere affected, the second a aooj and the fifth a daughter. 
The third daughter was the grandmother of my patients ; she 
was born next to the last and had an extra finger on each 
hand. The youngest daughter was unaffected and remained 
unmarried. 

The grandmother gave birth to seven children, five sons and 
two daughters. The eldest, a daughter, had one extra finger, 
and she had no family. The second, a son, had six toes on 
one foot, seven on the other, and fire fingers and a thumb on 
each hand. He had five children, four sons and a daughter. 
Three of the sons, the two elder and the youngest, were the 
subjects of supernumerary digits, whilst the daughter and one 
son escaped. The third, a eon, vaa normal, and his twelve 
children were all normal also. The fourth was a female, who 
escaped j she had no family. The fifth was the father of my 
patients. He had six toes on one foot, seven on the other, 
with the inner toes webbed, fire fingers and a thumb on one 
hand. His eldest son had harelip and cleft palate, and a web 
between the big toe and one adjacent in each foot. The second, 
third, and fourth children, two girls and a boy, escaped. The 
youngest son, an infant, was born with fire fingers and a thumb 
on each hand, six toes on each foot, and a web between all the 
toes. The sixth son (uncle of those last described) was normal, 
and he had three normal children. The seventh and youngest 
son was also normal, and has one normal daughter. 

It is worthy of note that the cleft palate and harelip present 
in one of the children described, was foreshadowed in a harelip, 
which occurred in a great uncle. 

As it is probable tfaat a tendency to the production of 
superfluous fingers and toes runs in but few families, and as 
other observers may meet with different branches of the same 
family I think it right to publish the names of those whose 
descendants have incurred a liability to this deformity. 

The family came originally from Suffolk, and the maiden 
name of the great-great-grandmother mentioned in the chart 
was Dawley ; after marriage her name was More. The grand- 
mother's maiden name was Collins and the tendency shows 
itself in hdr brothers and sisters named Collins, Mendham, 
and Hammond. She married a Phillips and there are eight 
of this name in whom the deformity has shown itself. 

. „Gooj^lf 



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ON CHRONIC NASAL OBSTRUCTION: 

I. OZ^KA. 
n. ADENOID GBOWTHS OP THE NA80-PHARTNX. 



Bi C. H. QOLDING.BIBD, B.A., M.B. 



Chbohic obstrnotion to the naul passagei is a veiy common 
eUnieal symptom, complained of by patieotB, of a nuriety of 
pathological conditions^ which, as a rule, only careful investi- 
gation can differentiate ; and their further ireqnent statement — 
without foundation — that they hare polypus, is at first mis- 
leading. 

A record having been kept of such cases daring especially, 
though not exclusively, the last three years, the following 
analysis and classitication may be made of them. It will 
inclade all those oonditions that commonly are seen in ordinary 
hospital and out-patient practice. It therefore does not inclade 
very unusual states, t. g. the presence of rhinoliths. 



" Stcffinxss " OR Chkokic Nasal OBSTatrcTioN. 

1 . Usually without any dtsoharge and not variable with the 
state of the atmosphere, 

Tumonra (except gelatinous polypi)^ snch as papillomata, 
enchondzomata, sarcomata, ntevi. 

Dig tizedoy Google 



423 On ChrotttC Natal 06itntetion. 

DiBpIacemeDtB or bendiugg of septam nasi, natnral or 

acquired. 
Chronic inflammator; thickening of mncoas membrane 
of inferior spongy bone. 
2. With anterior nasal discharge of vatery character, worae 
in damp weather. 

Gelatinous polypi. 
8. With posterior nasal moco-purulent discharge, especially 
of a morning ; ' dead pronunciation.' 

Adenoid growths of the naao-pharynx. 
4. With fetid anterior nasal muoo-puruleot or sangnineoos 
discharge. 

The varieties of oztena. 
Only the two last-mentioned classes will in this commnni. 
cation be illustrated with cases and remarks. 



Ozeena includes all cases of offensive rhinorrhoea. It is a 
clinical expression for complex pathological facts. It may 
affect one or both nostrils, and is, as will be shown, mostly 
constitutional in origin, although some acoideatal circumstance 
may be the immediate provoking cause. 

Since the strumous diathesis is credited with a large share 
in the production of oztena, an appreciation of this condition is 
first necessary. The scrofulous or strumoaa and the tuberculous 
were formerly, and are still by some, considered as different 
diatheses, but a more extended pathological knowledge, coupled 
with a less firm faith in complexions and physiognomies, is 
causing both to be considered as one ; and without now going 
into the arguments pro and eon, it may be mentioned that 
the histological likeness of tubercle to many of the local 
scrofulous manifestations, and the frequency of strumous 
children being horn of tuberculous (phthisical) mothers, are 
of themselves facts of no slight importance. 

For the purposes of this communication the word strumous 
will be used as expressing this one diathetic condition. 

Like all diatheses — and as to the matter of that, like every- 
n pathology — ^the strumous diathesis is but a breach in 

Google 



On Chrome Na$al Obiiruetien. 423 

the fulfilment of a fandamental phyiiological law, in this ease 
the law of growth ; and we may thas express it from its three 
points of view. PhynohgicaUy, it is au imperfect fulfilment 
of the law of development ; clinically, it is known as a coa- 
ditioD of had repair and bad resistance, or, in other words, 
slowness in healing, with a tendency to very chronic inflam- 
mation on the slightest provocation; pathologically, it is a 
dyscrasia of the lymphatic system. Begarding the last, it 
mnst ha said that the word " dyscrasia " is a convenient limbo 
to which to consign all those undetermined conditions that are 
awaiting elacidation, and commits the user of it to nothing more 
than that there is "something wrong." There are many 
manifestations of the diathesis which at ooce suggest the 
lymphatic system as the one at fault ; in others it is not so 
evident, and this arises &om the fact that they are in the form 
of inflammations and modes of repair, which one is so aacos- 
tomed to associate with the hlood-vascnlu- system. It mnst 
suS^ at present to say, however, that evidence is accumulating 
rapidly which shows that not the blood, but the lymphatic- 
vascular system, is the more important factor at work; and 
this admission once made there is no difficulty in associating 
a chronic strumous catarrh of a mucous membrane, with the 
more evidently lymphatic process of chronically enlarged 
glands, whether in the same or different individuals. 

A liability to chronic catarrh of the mucous membranes is 
a prominent symptom or mark of the strnmons condition ; 
and considering how common in the population generally a 
" cold " is, and in how very few proportionately it ansumes a 
downright chronic character, the custom has been — and a very 
proper and reasonable one too — to regard those cases that 
become chronic as belonging to the strumous diathesis, 
whether they show or not a particular cast of countenance, or 
shade of complexion, or have a particularly suitable family 
history. Now, in a very common form of ozsena, to be 
directly described, the patients almost always state that it 
began as a cold in the head ; and hence some writers on the 
subject class these by themselves as showing the results of 
catarrh of the nose or coryza, and put the strumous cases 
separately, although there is, by the time they appear before 
the surgeon, no evident clinical difference between them, 

. , Gooj^lf 



424 On Chronic Nasal Obatructian. 

It BeemB a pity that auch a diatmction ahould be made, and 
the more so as the renson given for caaea of coryza appearing 
later on an ozcena is that they are strumoos, while do prac- 
tical advantage is gained by sach a eUssificatioa. If alao the 
surgeon takes one patient's word that the disease began in a 
cold, and thereupon puts it down as catarrhal, and then 
another's that he had no cold and calls it strumoua, while both 
at the time of observation give the same objective BymptooiE, it 
is maDifest that a distinction is made upon the least reliable of 
all clinical grounds. The objective symptoms are usually 
sufficiently evident to enable each case to have its place allotted 
to it by these means ; and where the same local changea may 
belong to two different remote causes, then the history of the 
patient, e. g. as to struma or syphilis, must settle the question. 
Snch a method is adopted here. 

While as at first stated all cases of offensive rhinorrboaa 
belong to the genus oziena, only those in which the origin is 
intrinsically nasal vill be here mentioned ; and thus cases 
(such as necrosis of the hard palate) beginning elsewhere, but 
ending in the nose, will not be taken into account. 

The patient suffering from ossena generally complains of 
stuffiness in one or both nostrils, more frequently the former, 
a foul state of the breath, and a stinking muco>purulent or 
sanguineous discharge from the anterior nares, and only occa- 
sionally down the throat. Accompanying the discharge are 
" crusts " or scabs, or even pieces of bone. The " crasts " 
appear with tolerable regularity, beiog formed in a few 
hours in some cases or a day in others; they are blown 
down or removed by the patient, new ones then taking their 
place. In any one case the " crusts " are mostly of one size, 
as though formed always over the same — and that a limited- 
area. Bone when discharged is only so at long intervals, per- 
haps once or twice in many months, but the patients often 
call their " crusts " bone. They further, in by far the larger 
proportion of cases, volunteer the statement that they are 
suffering from polypus, but the absence of an anterior watery 
discharge alone will suffice to render the surgeon sceptical. 
The foul smell, so obvious to his friends, is at times denied by 
the patient ; this is from one of two causes : there is anosmia 
either from inflammation having destroyed the fnnc^on of the 

D,9Z.c:,y Google 



Oft Chronic Natal Obitruction. 425 

Schneiderian metabrane, or from the patient himself being 
80 used to the odour that he no longer appreciates it ; this last 
is known by testing him with other odoriferous substances. 
Where, however^ real anosmia exists, the appreciation of flavonr 
— taste, as the patient says — ia also lost, the vapour of the 
Bubetance tasted, though carried up throngh the posterior nares, 
fails to excite smell, thence the inability to recognise 
"bouquet" or "flarour;" taste, pure and simple, is always 
intact. Occasionally there is severe firontal " stu% " headache, 
worse on stooping. Tenderness of the nose is a very variable 
symptom ; sometimes the nares are excoriated, either from the 
cause of the OEtena or the result of the acrid dischat^ ; there 
may be acute external sweUing and redne8s,'or pain is complained 
of on pressing on the nose at various parts. One spot of pain, 
however, it is very important to recognise, since it points to an 
extension of the inflammatory process. It is teodemeas on 
firm pressure over the frontal sinuses, at times, but not 
always, accompanied with similar tenderness on the bridgs of 
the nose. It is not a mere superficial pain ; there is nothing 
visible and no cutaneous redness, but firm pressure at once 
makes the patient call out, when before he probably was not 
aware of anything wrong so high up. 

This indicates infiammation in the muco-peiiosteam of the 
frontal sinuses, and being a late symptom points to extension 
having taken place from the middle meatus up the infandi- 
bulum. In such cases it may be here anticipated that the 
surgeon is even more than ever guarded in his prognosis, which, 
omitting the frontal symptom, is already not too cheeriog. 

There may be visible deformity of the nose, apart from the 
appearances of acute inflammation already mentioned. The 
usual chronic changes are sinking of the bridge of the nose, a 
general " spreading out " or thickening of the bridge and carti- 
laginous parts, resembling the appearance seen in polypus cases, 
or a lateral displacement of the central parts, sending the 
point of the nose quite to one side. 

While the deformity may be the result of an actual necrotic 
process, as is usually seen in syphilitic cases, it may certaioly 
occur without any evidence of this having taken place. The 
increased breadth of the nose, while following loss of the 
septum, may also result from thickening of the tissues cover- 

Googk 



4S6 Om Chrome Natal OiifrwtioH. 

iag the natal bones; and the lateral bend in the septnin 
appears to be dne to the cbronio mnco-perioetitis or peri- 
chondritis baring so affected the oartilage that it loses its 
natural stifiheas and resiliency. This is but surmise, there 
being no histological eFideace of it as jet ; but it is certainly 
nntme that all cases of displacement are caused by loss of 
tinne by necrosis. The history of the case, together with 
direct obserration, can often disprove this. 

The following cases are selected from about thirty oonse- 
cutire ones, mostly occurring in my out-patient practice. 

They are thns arranged : 

I. Conttitutional ozmut. 

a. Stmmotu. — This manifests itself in the eatarrkal 

or in the iv^etiginouM form. Two of the impe. 
tiginoua cases were immediately after scarlet 
fever, and might therefore claim a separate place 
as exantKematout. 

b. Syphilitic. — This again shows two forms, the eatar- 

rkal and the mucO'perioiteal or gummatout. 

II. Local ozana. — This inolades foul nasal discharge from 

blows or fractures, foreign bodies, as clots, plugs, 
sloughing tumours. 



I. CONBTITUTIONAL OlANA. 

a. Strvmout, 

The simplest case noted was that of a gentleman, about 19 
years of age, whom I saw in 1676, Six weeks before, he had 
a cold, which in a month gave rise to an offensive rhinorrhcea 
from one nostril. Two days' constant inhalation of Vapor 
lodi, however, cured him. It is exceptional to see a case so 
early, and certainly to cure it so quickly. 

Case 1.— Emily W— , set. 21, out-patient, 16th May, 
1881. Four years* history of phthisis. Belicate looking, but 
nothing markedly " tuberculous " in appearance. Two years 
ago had cold in head, followed by much nasal stuffiness and 
foul discharge, but confined to right nostril. Used to syringe 
with water and bring down "crusts." Sreath offensive to 



.„Gooj^lf 



On CMnmie Nasal Oiatruetion. 407 

herself and otiien. Slight anosmia. Some pharyngeal dis- 
charge, which she hawks into the mouth. 

Sxammation. — Bight nostril : great congestion and puffl- 
ness of mncoas membrane ; inferior spongy bone swollen and 
granular ; an abraded patch npon it, now covered with a scab. 
Left nostril : redness of mucous membrane of septnm j scab on 
outer wall; inferior spongy bone normal. Digital examina^ 
tion of naao-pharynz showed nothing wrong except much sticky 
dischai^e on wall of pharynx. 

Eemarka. — K common type of ozsena. Thongh the abrasion 
mentioned had just the appearance of "granular lids," yet at 
times ulceration is to be seen. Without a syphilitic taint 
I have never seen the nlceration descend deeper than the 
mucous membrane. 

Case 2. — Caroline S — , set. 17, out-patientj 10th Norember, 
1879. CruBts and foul breath for years (? fire years), and 
gradual depression of nose jnat beyond nasal bones. Pain on 
pressure over bridge of noae. Partial anosmia. Last fer 
weeks crusts have come down with the discharge on the right 
side only. 

Examiaatiim. — Left nostril blocked by bulging of septum, 
so that outer and inner walls of nostril touch. Bight side 
shows general velvet-like condition of all the visible mucona 
membrane, in part scabbed over ; ? if ulcerated. 

Case 8.— Mary D— , tet. 14, out-patient, February 10th, 
1879. A " strumons " looking girl ; Sat face, spreading nose, 
thick upper lip. No evidence of hereditary syphilis whatever. 
For years had pain in nose, and foul discharge and crusts. 

Examination. — Marked pain on pressure over the frontal 
sinuses and bridge of nose. Anterior rhinoscopy showed 
nothing wrong. 

Case 4. — George H — , x.i. 46, 14th July, 1879, out- 
patient. Cold in head last March ; since then foul discharge 
from right nostril, with crusts. At times stuffy frontal head- 
ache, slight pain on frontal pressure, 

Examination.^hoi&ivaT rhinoscopy showed nothiDgi^ 



428 On Chrome Natal ObttruetUm. 

Remarks. — In the tvo Uat casea there can be no donbt that 
the same process was going on in the nose as in Cases 1 and 
2, although, from the mere acoident of position, it was impos- 
sihle to see it. Both of them further give poBttive eridence 
of the high position of the disease by the frontal tenderness on 
pressnre. Case 8 presented the cast of countenance, which 
when present is an accepted sign of the stramoas diathesis, 
although its absence must not be taken as necessarily proving 
the contrary. 

Case 5. — Thomas L — , tet. 11, outpatient, 2Sth Angust, 
1879. (Brother to Case 9). Usual ozsena symptoms after 
a cold six months ago. A heavy-featured, thick-lipped 
stmmous-looking hoy. 

Examination, — Bight nostril showed a congested mnooua 
membrane and oblong ulcer about the size of a split pea on the 
septum ; it was very tender to touch. Nothing aeen on left 
side, though crusts come down both. 

JRemarks.—Uhe disease here was bilateral, but only on one 
side could anything be seen. The ulcer showed a later catarrhal 
change than in the preceding cases quoted. 

Case 6, — Eliza C— , set. 6, outpatient, 80th May, 1881. 
A fair-haired, pale, cachectic child. Has ulcerative stomatitis 
in lower jaw and simple stomatitis in upper jaw. Has had 
"breakings out" on face. Has had ozeena for many weeks; 
muco-sanguineous discbarge, crusts. 

ExamittatioR.—iio external swelling ; anterior rhiuoscopy 
showed spongy state, with sneUing of muco-periosteum of 
both sides of septum, and similar state of right inferior spongy 
bone. No ulceration ; no crusts seen. 

Bemark*, — Occasionally the coincidence of stomatitis with 
oztens is seen. May such cases be taken as throwing a light 
upon the general pathology of catarrhal strumous ozena ? It 
is likely, at least, that the muco-periostitia is the same both in 
mouth and nose. 

Case 7.— Miss C— , mt. 16, 80tb April, 1881. Had been 
for four months under treatment for early spinal caries. 
Within the last three weeks has had impetiginous eruption on 
upper lip and about the nostrils, which gradually spread up 



Gl.)(.K^Ic 



Ok Chrome Ifaaal Ohttrnctim. 429 

the nose, and was followed by foal discharge and cniBta. The 
crosts rapidly re-form if removed. 

Examination. — Both nostrils nearly blocked with impeti- 
ginoQB scabs, and breach of surface seen in the septatn (pro- 
bably trsTunatic from pickiDg], 

Cabb 8. — Miss F— , EBt. 21, 23rd June, 1881. For a long 
time has been under treatment for scrofulous glands of the 
neck. Last summer snffered from eruption abont upper lip 
and nostril, it spread up the nose and then followed fool 
breath and discharge and crusts; it was cured with some 
ointment (Ung. Hyd, Nit. dilut). This summer it is just 
recommencing. 

Examination. — Impetiginous eruption just inside the left 
nostril ; slight external redness, no ozena as yet. 

Cass 9.— Ellen L— , set. 7, out-patient, 7th June, 1880; 
sister to Case 6. One month ago had a " sore nose," followed 
by foul smell and discharge. Now only impetigo of nostril 
extending into nose to be seen. Same cast of countenance 
as her brother. 

Cass 10, — James J — , tet. 8, out-patient, 18th June, 
1881. A delicate-looking child ; still looking pale from 
scarlet fever one month ago. Has patch of impetigo on right 
brow, and others about lips and nostrils. Foul smell j dis- 
charge of crusts and blood &om nose. Frontal pain on pres- 
sure ; iiontal headache. 

Bxmnination, — Whole nose much swollen and very tender ; 
both nostrils quite blocked with crusts. Naso-pharynz con- 
tains fine adenoid growths. On June 20tb, the crusts being 
removed, in the right nostril there was much mnco-pnmlent 
dischai^^ seen, in the left some crusts ; in both great hyper- 
«mia of the m.ncou8 membraDe. The whole nose much less 
swollen. No foul smell now. 

Cask 11. — Annie M — , st. 18, out-patient, 5th October, 
1880. Scarlet fever one year ago ; since then has been troubled 
with eruption abont nostrils, stuffiness in breathing, discharge 
and crusts, but no bad odour, 

£j:affMna/ioR.— Each nostril completely blo^ed with impe- 



„Gooj^lc 



460 Oh ChronU iVwaf Oii&uclitnL 

tiginoui eruBts, conuDg from eolnma of nose and alie. No fool 
breath. 

Remarh. — These five cases illustrate well the oondition of 
OBteoa from an impetiginous eruption. In Cues 7, 8, and 9, 
there vere other manifestations of the strnmous diathesis, and 
impetigo is of itself a recognised diathetic rash. In Cases 10 
and 11 the disease followed upon scarlet fever; jadging from 
the exanthemstons manifestatioDB in the mouth, we would 
rather have expected a severe mnco-periostitis ; the rash of 
impetigo toaj, therefore, have been little else than a coinci- 
dence. That both were^ however, the same is worthy of note. 
Caw 11 showed all the signs (save the foul odour] that go 
to make a case of impetiginous ozEena ; and, as the odour 
depends on the accident of putrefaction, and not upon any 
intrinsic pathological peculiarity, it is introduced here. Simi- 
larly catarrhal cases may be seen in which the smell is absent. 
Such a case is the following : 

Case 12.— Rose H— , tet. 21, out<patient, 18th Septem- 
ber, 1880, Suffering for six months with rhiuorrhcea and 
discharge of crusts, but no bad smell. 

Examinaiion.—Jiight nostril appears normal. Left nostril 
shows mucous membrane spongy, injected, and easily bleeding ; 
much muoo-porulent secretion. 



b. Syphilitic ozana. 

Constitutional syphilis is, next in frequency to the atmmous 
diatbeBiBj a source of oztena. One class of cases is not to be 
distinguisbed, usually, from the strumous catarrhal, the 
history alone, unless there are other specific marks on the 
person, being the guide as to origin. That such should be the 
case would be expected on reflecting how like to the stru- 
mous are so many of the constitutional syphilitic manifesta- 
tions — the lymphatic system in both markedly suffering ; hence 
"bad repair," "had resistance," aud tendencies to catarrh. 
The cases here quoted illustrate the two varieties of osana 
commonly seen in syphilis, omitting mucous tuberole, which 
cauaes "snuffleii" uid rhinorrbcBa, but net bad odouf, in 



Dig lized^y Google 



On Chrome Natal Obttmetion. 481 

infants. They are the catarrhal and the muco-pvrioateat or 
gummatout. 

As an example of the catarrhal the following case is giveu : 

Case 13. — Mary W. tet. 81, out-patient, 26th May, 1879. 
A case long under treatment for constitutional syphilis. One 
year ago had a cold, followed by rhioorrhcea that became 
offensive ; then stuffiness in nose, relieved hy " easing down 
with a hair-pin " some crusts that used to block it up. 
Breadth of nose has been gradually increasing, but there has 
been no linking of the bridge. 

Examination, — Nose as far as seen lined with crusts; 
superficial ulceration, and some impetiginous scales about the 
nostrils; these sores were subsequent to the other symptoms, 
and apparently due to the irritation of the discharge. 

Cabb 14. — John W — , set. 29, out-patient, 2nd May, 
1881. Contracted syphilis three years ago ; has had rash and 
constitutional symptoms. Three months ago had complete 
stoppage of the right nostril, which continues at present. No 
discharge from nose ; not worse in wet weather. No foul 
odonr. 

£fainin<i/ion.— Externally the right nostril, at junction of 
bony and cartilaginous wall, presents a tender, red, aemi-flnc- 
tuatiQg swelling, which from inside is seen to grow from the 
septum, to extend across the nostril, and protrude the outer 
wall, aa above. The mucous membrane is red and inflamed. 
The left nostril is normal. 

Case 15. — William H— , let. 40, ont-patient, 23rd Feb. 
ruary, 1880. An old syphilitic patient. The last year has 
had stoppage of the lefl nostril, but no pain. Six months ago 
something burst in the nostril, discharging a teaspoonfol of 
matter, and ever since then has had crusts and foul discharge 
come down. No pain even now, and no external swelling and 
deformity. No frontal pressure, pain, nor headache. When 
the nose first became bed he bad tender lumps (nodes) on the 
head and forehead. 

Examination. — In left nostril a large scab seen on outer wall, 
which was removed, and then the muoooa membrane waathera 



Dig lized^y Google 



4d2 Oil Chrordc Naaat Obslruetion. 

found Bnperficitilly ulcerated. No proof of any necKwis of 
bone as yet. He rapidly improved witli iodide of potauiam. 

Case 16. — Robert S — , st, 30, out-patient, IStli June, 
1881. Had Bome veuereal complaint nine years aince, but is 
very reticent on the point; can get no positive evidence of 
syphilis {unless in the nose) and the remedies. Has bad pain 
in right nostril and right side of bridge of nose two months 
ago ; at first it was all internal, hut afterwards the outside of 
the nose became tender. Lately has had sensation of some- 
thing mnning down throat, and laet week had blood come 
from the right nostril, but no discharge of matter; very foul 
breath. 

Examination. — Bight nostril shows macons membrane very 
injected ; high up on septum is a conical tmucated swelling of 
the muco-periosteam ; and crater-like, at the top, is a depressed 
ulcer. It has the appearance of something having formed 
under the mucous membrane and subsequently burst outwards. 
In two weeks all his symptoms vanished with anti-syphilitic 
remedies, but the swelling had not quite subsided. 

Case 17. — Abraham S — , set. 45, ont-patient, 6th Decem- 
ber, 1880. Syphilis seven year^ ago. For the last six yekrs 
has had constant buzzing (like machinery in motion) in left 
side of head, better when in the open air than in a close 
room ; lately this noise has extended over to the right side. 
UndiminiBhed by pressure on carotid ; no exophthalmos ; no 
cranial bruit, The noise (pain, he calls it also) varies from 
day to day. When it began there was also very foul discharge 
from the nose ; the bridge of the nose has been gradually 
sinking. Patient has pained expression ; is very ancemic. He 
rapidly improved under iodide o£ potassium, and on April 35th, 
1S81, a piece of bone came away from nose. The septum is 
now perforated, and there is more bone loose. 

Bemarh. — These four cases give the stages of gamma in 
the nose ending in veritable ozsena. Tbe absence of foul 
smell in Case 14 does not prevent its being quoted here as an 
early state of the disease. The other cases, speak for them- 
selves. Case 15 is regarded as one of gummatous periosteal 
abscess, suddenly discharging. 

Dig zec.yGOOg[e 



On Chrome Natal Ohtttuelion, 



II. Local Ozana, 

BlovB oa the nose, aa might be anticipatedj account for 
BOtue cases of ozeeiia. At times the injury at once prodoces 
death of tisBue, aad symptoms of ozseDa: in other cases it gives 
rise to a muco -peri ostitis, resembling the ordinary catarrhal 
affection ; perhaps in these last there is a stramous tendency 
or diathetic condition present. Thus — 

Cabb 18, — Francis S — , nt. 9, out-patient, 27th June, 
1881. A year age Tas struck on nose with the handle of 
a door; there tras jauch epistaxis; since then the bridge 
of the nose has gradually been widening out. Three weeks 
after the accident offensive rhinorrhoea, with crusts and 
blood, commenced and still continues. 

Examinatuin. — No external redness, only the deformity o£ 
nose ; internally only the usual catarrhal appearances seen ; 
no proof of dead bone ; the mucous membrane of both the 
inferior spongy bones was very thickened, so as on the left side 
to block the meatus. 

In the following case ozsna followed the blow directly. 

Casb 19. — Helen M — , set. 26, out-patient, 19th May, 
1879. A healthy woman ; married ; not syphilitic. Blow 
on nose six months ago; it did not bleed. Three weeks 
afterwards there was discharge of blood-clots and matter, and 
of crusts, with foul odour. The nose was then very painful 
and sore, and it has gradually altered in shape, the bridge 
sinking down. Six weeks later first felt loose bone in nostril. 

Examination. — Pain on pressure over nasal bones, With 
the speculum the anterior inferior part of vertical plate of 
ethmoid is seen dead and exposed, bat still fixed. 

Other local causes for ozEena, that may be called accidental, 
need bat be mentioned, as foreign bodies in nose and rhino- 
liths, retained blood-clot or sponges, shreds of mucous mem- 
brane sloughing afler manipulation, and polypi imperfectly 
removed (or that have been tied) becoming gangrenous. 

"'■'"'■■ '?Googk- 



434 .Ob Chronic Nasal Obatruetion. 

Treatment. — The mechanical difficulties met with, and not 
anything intrinsically hard to deal with ia the pathological 
conditionB of oziena, are the causes of disappointment in the 
treatment of this disease. 

Amongst all classes of life the same aoatomically devious 
paths along which medicaments have to travel in the nose 
are found of course ; but among the poor the want of time 
to give sufficient attention to treatment is a great drawback 
to success. Many, too, of this last class, upon losing 
the foul smell and knowing how to keep up the improvement, 
cease to attend the hospital, and so still further reduce the 
number of radical improvements and cures. 

In all cases, cleanliness, even without antiseptics, is 
essential, and suffices to get rid of the smell. The aasal 
douche with glass rose (" wateriug-pot ") nozzle is best ; but 
the new form of Higgenson's vaginal syringe, with a " rose " 
nozzle, answers well. A syringe with a single jet is all but 
useless, the fluid being sent along the inferior meatus and not 
thrown into the upper nasal passages. 

After uaing whatever is ordered for cleansing the passages 
and removing the crusts, the remedies, if liquid, may be 
thrown up in the same way, or more efficiently as a spray. 

For cleansing, weak salt and water ia as good as aaytfain^, 
used in quantity ; or carbolic lotion or Condy's fluid can be 
used instead ; but these, whilst antiseptic, do not wash the 
mucous membrane so well as the weak alkaline solution of 
salt. 

In catarrhal cases astringent lotions, as of alum and zinc, 
may be used in bulk after the nose is cleansed ; or where the 
mucous membrane affected Can be seen and reached, a solution 
of nitrate of silver (5 — 10 grs. to 3j) or sulphate of copper 
(5 grs. to 3}) should be used, with a camel-hiur brush or aa 
spray. Where ulceration can be seen, the Ung, Hyd. Nitrat. 
Mit. (Phar. Guy.) painted on, suffices. In cases of frontal 
pain, the inflammation having travelled up the infundibulum, 
volatile substauces must be used ; and T am accustomed to 
employ iodoform (30 grs.) mixed with starch and zinc powders 
(uf each ^ oz.). The proportion of iodoform must be altered 
so as to suit each patient's sensibility. In other catarrhal 
cases, genernlly strumous or syphilitic, iodoform ia certainly 



Go.K^lc 



On Chronic Nasal Obstruclion. 435 

beneficial ; and I usually add (foUoning Trousseau) 5 grains of 
red oxide of mercury to each ounce of the " snufiF." In 
impetiginous ozteDa, softening of the scabs, which so plenti' 
fully block the nose, must be done with glycerine, and then 
the weak mercurial ointment be put on the exposed sores. 
If the case is seen early these will be within reach of a brush; 
if late, then after removal of crusts, weak stimulating lotions 
(sprays); as nitrate of silver gr. iij to 3 j, are good. 

The moat hopeless (for the time) of all cases are the 
syphilitic necrotic cases ; until the bone comes away, or is 
removed by operation, it is hard work even to keep the odour 
under ; as deodoriser, iodoform is here useful. 

Once I saw counter irritation do much good for the time 
in a girl cet. 13. Since two years of age she had had enlarged 
cervical glands that broke in 1878. At that time she had 
catarrhal ozEena with foul discharge and crusts. All this 
rapidly subsided for the three years that the glands remained 
open, but when they healed up, in 1881, the nasal discharge 
at once began to appear, although the child's general health 
had very much improved. Had the good result of the counter 
irrttalion been permanent, it would have suggested a seton 
in some obstinate oziena cases, but hardly so as it was but 
temporary. 

Id constitutional ozsena local treatment must be combined 
with the general treatment adopted in such states. 



AniNoin tiaowTHs of the NasO'PHarvnx. 

Although pathological enlargement of the lymphatic tissue 
of the naso-pharynx has not yet received the place it deserves 
in English surgical text-books, yet since Meyer's first descrip- 
tion of it,' good accounts are to be found in writers specially 
devoted to the diseases of the larynx and pharynx.' 

A mere outline of the more prominent symptoms is all 
that will therefore be given here, and the cases quoted will 
only be those of adults in whom the disease is far more 

' ' Meilico-Cbimrgical Tranwction*,' vol. liii, p. 191, " Adenoid Growths in tbe 
NflBO-Piiarjiu," W. Meyer, of CopcDhageD. 
* See eapecidij Cohen, ' DUeuei of tho ThnMt,' Ne<r Tork, 2ad editiou, 1S79< 



.ylc 



On Chronic Nasal Obstruction. 

inlly met vith than in the youDg. Coben,' indeed, 
remarks (p. 258) : " Moat of the cases Been by myself have 
been in young ndult malea. In one instance I have had 
occasion to operate on two adolescent sisters. I have never 
seen it in advanced life." Meyer puts the most frequent age 
as between 5 and 25 — rather a wide range 1 but believes it to 
be more frequent before ten years of age than afterwards. It 
is, as far as I have seen, most likely to be complained of as a 
pnthological condition of young adults, for obvious reasons; 
yet if systematically examined for at all ages, irrespective of 
clinical symptoms, Meyer's statemeut would very likely be 
found quite correct. Whenever I have seen it in children it 
has been when examining for something else, and not because 
any definite symptom of its presence was visible. It will 
thus be seen that increased interest attaches to at least two 
of the cases here given, aged 50 and 40 ; they are the oldest I 
have met with either in practice or recorded. 

The paiholoffy of the disease is merely a hypertrophy of the 
normal lymphatic (adenoid) tissue found in the mucous mem- 
brane of the pharyni. When high up in the naso-pharynx it 
goes by the name of " adenoid growth of the naso-pbarynx,'' 
but when placed lower down and within view from the 
mouth (though here it is probably etiologically different), it 
becomes " granular sore throat," " chronic lymphadenitis of 
the pharynx," " Parson's sore throat," with about twelve 
other aliases. 

A very good description of the minute and histological 
anatomy of the naso-pharyngeal lymphoid tissue and its 
hypertrophy is to be found in Cohen's work, already referred 
to, where he quotes largely from Luschka, The result of all 
microscopical observations is to show that the hypeitrophied 
nodules are lymphoid tissue. In two of my own casea which 
I have examined (one being that of the woman set, 40), the 
growths Irom the naso^pharynx, where prepared as microscopic 
sections, are perfect examples of this tissue. 

Woakes, in his 'Deafness and Koisea in the Head,' ed. 
1880, speaks of the growths as papillomatous. There is no 
sound reason whatever given for such an assertion ; it is 
quite unsupported and only mentioned here &s a caution. 

Dig zee. y Google 



On Chrome Nasal Obstruction. 437 

The hypertropliied tissue is as soft as velvet, easily torn, and 
very vascular ; accompanying it is a chronic catarrh of the 
mucous membrane, and hence the niuco>purnlent foul nasal 
discharge. 

When adenoid gronth of the naso-pharyux gives rise to 
symptoms, they are usually of sufficiently deGnite character to 
enable the affection to be diagnosed vrithout physical esamiua- 
tion, if the surgeon has once seen a case, otherwise the patient 
is likely to be passed over as merely the poBaesaor of a common 
cold. It may not uufrequently be detected, in the drawing 
room, in young people when singiug — there being an absence 
of clear ring in the voice that no amount of practice or vocali- 
sation can get rid of. Mild, perhaps, in such cases, this 
symptom, when aggravated, causes a marked absence of nasal 
resonance— a " dead " pronunciation, as it has been called — 
owing to the blocking of the posterior nostril : and hence the 
patient comes for relief from chronic nasal stuffiness. Without 
actual stoppage of the nose the voice loses its clearness from 
the soft growth acting ns a damper in the nasal "resonator." 

There is a sense of fulness in the throat, with a feeling 
of something there which must be swallowed or hawked up, 
and which is often then streaked with blood ; and a constant 
discharge down the pharynn of muco-pus, which is worse in 
the morning, and at times gives rise to a morning sickness. 
When in bed, first one and then the other nostril gets 
blocked, and then always the one toward the pillow. There 
is a dry, ausatisfactory feeling in the nose, to relieve which 
the patient is constantly wringing the organ, even producing 
bleeding and excoriation. The patient when not talking 
keeps his lips apart, and of a morning complains of great 
dryness from having had to breathe all night through the 
open mouth. 

A digital examination of the naso-pharynx through 
the mouth is more satisfactory than the rhinoscopic, and 
reveals either a velvety granular growth from the posterior 
wall (rarely elsewhere) of the naso-pharynx, very soft 
and easily wounded, or a larger growth, that has been 
compared to a number of rather small leeches hanging on to 
the mucous membrane. The former condition is the more fre- 
quently found, The examining finger will bring away always 



438 On Chronic Natal Obstruction, 

some falood'Stained mncua, aod often the translucent millet- 
like grains, or which the growth w composed. 

On examining with a good light the wall of the phai^nx 
below the level of the palate, exteosioD of the disease down- 
wards may (but not always] be seen j but a thick, tenacions 
discharge trickling down is so common as of itself to suggest 
adenoid growth above, even if not otherwise indicated. 

Deafness, due either to the growth having affected the 
opening of the Eustachian tube or to accompanying catarrh, is 
so commonly seen that Meyer summed up the diagnosis thua 
tersely by saying " a deaf patient who breathes through his 
mouth has probably adenoids." 

Such a combination of symptoms as that glanced at above 
can point to but that one disease; for while polypus gives 
many similar indications, the influence of wet weather, the 
variability in the stuffiness, and the marked anterior discharge 
of water are unmistakable. Ozena necessitates a foul 
smell ; a " cold " has much anterior nasal catarrh, and 
anything bat a dry condition of the nostrils ; while phthisis, 
it is now seen, is not the only disease producing expectoration 
streaked with blood. 

The vomiting, especially of a morning, requires more 
notice j and as illustrating this form of throat sickness, two 
cases are added which, though not strictly belonging to the 
class under consideration, are so closely connected with it that 
their mention will add to the completeness of the description. 

Where the hypertrophy of adenoid tissue is confined to the 
naso-pharynx, the sickness, mostly of a morning, seems due 
solely to the fact of thick mucus trickling down the pharynx : 
the constant habit of hawking and spitting having increased, 
to a morbid extent, the naturally reflex sensibility to tickling 
the fauces. 

When the disease is visible in the pharynx (whether also it 
exists or not higher up), the vomiting and retching seem to 
be the result of the extreme sensibility of the patches of 
adenoid growths themselves. When sometimes ulcerated, the 
pain of them is such as to produce dysphagia or even an utter 
impossibility to swallow anything hot or solid; an attempt to 
do this producing at once contraction of the constrictors, and 
hagismus and the return of the food by the ^outh and 



On Cftronje Niuat Ohtruelion. ' 439 

nose. The whole muooQa membrane of the pharjrnx in these 
cues IB very injected and abnormally aensitive j and not a 
few of them, as has been often observed, are in people of 
pecttliarly " susceptible" natures. 

In Cases 4 and 5 the nlceration occupied the salpingo- 
pharyngeal folds, and hence explained both the pain in the 
ear and the extreme agony caused by any attempt at sirallow- 
ing. Zaufal' considers these folds are of more importance 
in closing the naso- pharyngeal cavity in deglutition than even 
the soft palate, and the pain accompanying their ulcerated 
condition would alone warrant the statement, apart from 
other observations. 

That the enlargement of theae folds of mucous membrane 
was due to lymphatic swelling in these cases was founded upon 
naked-eye appearances, together with the fact of there being 
adenoid growths elsewhere in the pharynx. 

So extreme was the dysphagia in Case 5 that abe had been sent 
for advice for probably malignant growth of the cesophagus. 

Dysphagia, then, with the stabbing ear-pain are tbe promi- 
nent subjective symptoms of this form of sore throat. 

The causation of theae adenoid growths is very obscure, 
bat being of lymphatic nature a scrofulous condition may be 
anticipated ; yet, while undoubtedly scrofulous manifeatations 
in physiognomy or in other ways may be seen at the same 
time in certain cases, especially in children, this is ao aeldom 
the case that the suggestion probably goes for nothing. 
Enlarged tonsils are also only an accidentally concurrent con- 
dition. The only constant peculiarity running through nearly 
alt my cases (all but one) has been an unusually narrow naso- 
pharynx measured fore and aft; hence but comparatively little 
extra growth completely blocks the posterior nares. 

Treatment. — This must be local, whatever general tonic 
treatment may be adopted besides. Astringents alone to the 
naso-pharynx, with carbolic acid to allay hyper sensibility, 
give relief but do not cure. " Scraping '' the naso-pharynx, or 
actually cauterising the growths, is the only effectual means. 
The former is better if thoroughly carried out ; the patients can 
moatly have it done without an ancesthetic, but they must be 
prepared to give several — perhaps half n dozen^-aittings. The 

enbeitkande/ 

, Google 



440 On Chronic Nasal Obitrvetion. 

actual CRutery (galvanic) has been UHed, as also solid nitrate of 
silver ; this last is useful aa on aid after the scraping has been 
employed, and is very paiDful for some hours. The action of 
scraping does not seem to be only that of removal, for one does 
not see come away as much of the growth as afterwards 
disappears. The bruisiDg action of the scraper starts inflam- 
mation, which seems quite as efl'ectual in curing aa the 
mechanical removal, even if not more so. The operation 
requires moderate care, as excessive inflammation, if excited, 
may bring the Euatachian tubes into trouble. 

There are various shapes of forceps also used to erulse the 
growths through the mouth if large, or to crush them when 
small ; but, except for the former purpose, scraping is more 
certain and easier to perform. I make use of Catti's forceps 
when I use any at all. 

All operative interference with these growths induces sharp 
oozing of blood ; but it never gives trouble, and syringing a 
little iced or salt water through the nose will arrest it, but even 
this is seldom necessary. 

The operation of scraping may be done by a fine instrumeDt 
introduced through the nose (Meyer's plan), or else through tbe 
mouth, which is more usual ; but in this case the scraper 
must be bent to pass under the soft palate. I have had 
a scraper made, here fignred, which aoswera admirably; it 




being, in fact, a sharp fenestrated spoon set at the proper 
angle. It acts from above downwards, but some surgeons 
prefer working from side to side ; for this a different instm. 
ment is required. A long foreflnger>nail does the work very 
well ; I never feel for adenoid growths without, if finding any, 
giving the naso^pharyox a good scrape before withdrawing the 
fineer. It is, however, much more nncomfortable for the 

. , GoeK^Ic 



On Chronic Nasal Obstntclian. 4il 

patieDt, because of its balk, tban the metal scraper. If 
nnsesthetised, the patient should be lying dawn with the head 
thrown well back, but if not he should sit facing the surgeon, 
with the head supported in the erect rather than the inclined 
position. With a rectangular tongue -depressor in the left 
hand, the right hand of the operator will be free to use the 
scraper, which should, as in all throat operations, be boldly 
and steadily introduced, without touching the tongue, beneath 
the soft palate. The scraping may be rapidly performed, the 
operation need not last more than ten seconds ; not more 
than half this time, however, being often allowed by an 
intolerant and sensitive patient. 

Case 1. Adeaoidt of na»o-pkarynx relieved by scraping 
mttcottS membrane. — Ed. M — , Eet. 50, out-patient, 26th July, 
1880. A, man of apparently average health ; no evident con- 
stitntiooal defect. 

Complains of stoppage of the nose, especially of the right 
side, daring the last five or six years. Has had during that 
time a constant feeling of discomfort in the nose, with great 
dryness of the passages, and he tries to rid himself of this 
feeling by the constant use of hiB handkerchief and sniffing, as 
thongh to remove something there. Air passes through both 
nostrils, but with difficulty. The constant wringing of the 
nose has given it a red and chapped appearance, and so much 
is it a habit that whilst talking he, at least every minate, gets 
out his handkerchief and blows hia nose, thongh nothing comes 
of so doing. He considers that he has a cold and complains 
much of the discomfort of the above symptoms. He has very 
marked dead pronunciation. As a general rule he breathes 
throngli the nose, and therefore does not carry the lips con- 
stantly apart. There is no anterior rbinorrhoea, but several 
times daily, and especially the first thing in the morning, be 
bos to rid bimaelf, by hawking and spitting, of much thick 
muco-pumlent matter that trickles down his throat, which at 
times makes him feel sick. 

Examination of anterior nares showed only a preternaturally 
dry and somewhat swollen and congested mucous membrane; 
no polypus, no ulcer. Digital examination of the naso. 
pharynx revealed a soft, velvet-like granular covering tQ all tlu 



443 On Chronic Naaal Obitrmtion. 

poiterior DKBo-phflrTDgeal wall, into which the finger-Qiil 
easily pHSBed, causiog free bleeding, and bringing away smal), 
clear, seed-like badies resembling grains of sago. 

The treatment commenced with a nasal douche (to be 
allowed to run out though the month) of glycerine and car- 
bolic acid. This gave much relief to the feeling of dryness 
and made the patient more comfortable. On September 17th, 
1880, he entered the hospital (Iiazarua Ward) for a few days, 
and under chloroform I thoroughly scraped all the naso- 
pharynx ; there was no difficulty experienced, the patient lying 
down flat with the head thrown somewhat backwards over a 
pillow. The bleeding was rather free, hut syringing with ice- 
cold water at once arrested it. On his discharge, tannic acid 
was added to the lotion first ordered. October 18th, 1S80, at 
the out-patients he was scraped again, without any anes- 
thetic. He now b^:an to feel relief from his symptoms and 
to use his handkerchief leas frequently. From this time to the 
end of the year he was again twice scraped, and also on 
January 10th, 1881, when I have this note : " Has been using 
Vapor lodi, is much better, comparatively little growth (naso- 
pharyngeal) now ; little hawking and spitting now ; less 
discharge in the throat of a morning. Finds the Vapor lodi 
gives much relief." The last note is February 7th, 1881 : 
" Above (i.e. high up in naso-pharynx) there is nothing prac- 
tically, but there is some still on level with soft palate ; scraped 
again. Patient considers himself well. Scarcely any poste- 
rior (morning) discharge. Can breathe through nose." Has 
not been seen since. 

Case 2. Strumous ozena ; adenoid* of ntuo-pharynx ; 
relieved by scraping. — Harry S — , set. 17, out-patient, 26th 
July, 1880. A lad of strumous appearance; has nose and 
upper lip swell in damp weather, when he easily catches cold. 
For a year has had stoppage of his nose at times, and there 
is much discharge down back of throat, which he hawks 
up. Never breathes through his nose, and keeps his mouth 
always slightly open ; has complete dead pronunciation. 

There is anterior and offensive rhinorrhcea with discharge of 
crusts. Of a morning his mouth is very dry from having 
breathed through it all night. 

Examination anteriorly showed nasal mucous membrane, 



On Chronic Natal Obatructien. 443 

especially of septum, red, TSBCulnr, and spongy, and easily 
bleeding; the swollen mncons membrane of the tvo walls 
nearly meeting at the narrow fissure between anterior and 
posterior nasal chambers. Digital examination showed small 
leech'like growths, pendulous from the posterior wall of the 
naso^pharynx, soft and easily bleeding. 

The treatment here was in the main that of Case 1, with 
the addition of Mist. Ferri et Qnassise ^, ter die. The patient 
had a most sensitive throat and resisted mechanical treatment, 
BO that the scraping was never so thoroughly carried out as it 
should have been. Between July, 1880, and January 10th, 
1881, the naso-pharynx was scraped four times, once under 
chloroform ; and the last note of the case is " much better, 
breathes with comfort, and of a night also through nose." 

Case 8, Nasal polypus; removal of adenoidt of naso- 
pharynx by scraping (From the report of Mr. H, E. 
Richardson). — Mary Ann H — , let. 40. First admitted into 
Mary Ward under Dr. Pavy, 13th May, 1881, and on the a^th 
was transferred to Martha Ward under Mr. Golding>Bird. 

The patient was taken in for treatment on account of dia> 
tressing ernctations after taking food, uneasiness over pit of 
stomach, and interscapular aching pain. She gave a history 
of phthisis on both parents' sides, and she herself had been for 
four years subject to chronic bronchitis. A year ago had first 
had stuffiness in the nose, and five months later several nasal 
polypi were removed at St. Thomas's Hospital; some were 
(she knew) left behind. 

The Toice is natural save for a thick intonation due to the 
polypi. 

On May 30th, Mr. Golding Bird snared and removed some 
nasal polypi, and on the ^7th she was transferred to Martha 
Ward for the operation to be completed, it being known that 
there was a large naao-pharyngeal polypus blocking the left 
posterior nostril. An attempt had been made on the 20th to 
remove it with the others, but without sucesa. The following 
note was made in the surgical ward: — "At the first sitting, after 
clearing nostrils (of gelatinous polypi), a large naso-pbaiyn- 
geal polypus was found blocking the left posterior nostril. 
Three attempts to " wire " it. Bell's fashion, failed. This 

. , Google 



444 On Chronic Nasal Obstruction. 

morning a dark gftDgrenonB mass had been forced down to 
the aaterior nostril, which proved to be the above polypus, 
destroyed by the first day's manipnlation ; it was easily 
removed now from the nostril. A further examination of the 
naso-pharynx showed velvet-like f^wtb of adenoid tissue 
from its posterior wall; this was crushed with Catti's forceps, 
some being removed for microscopic examination." 

Patient discharged the same day and has not been beard of 



Case 4. Granular pharyngitis (localised) ; severe symptoms ; 
dysphagia ; relief by caustics. — Ann B — , Bet. 50, oat-patient 
November 29tb, 1880. A generally healthy woman ; no 
constitutional defects. Two months ago seized rather and. 
denly with severe pain in the throat, very much worse on 
swallowing anything at ail hard ; the pain is referred externally 
to the angle of the right lower jaw. The pain has increased 
and now is most acute, flying up into the ears (riglit especially) 
as though a knife were being driven into it from within. Even 
when swallowing her saliva there is much pain, but the cutting 
sensation just mentioned is paroxysmal and induced by 
swallowing anything in the way of food. It is ao intense now 
that she is unable to take enough to eat ; she is losing flesh 
and looks very wan and ill. The pain markedly increased a 
fortnight since. 

On examination, there is to be seen on each aide of the 




'flrior wall of pharynx and partly under cover of the posterior 



On Chronic Naaal Obatrvetion. 445 

pillars o£ the fauces, a lineal growth of granulation-like tisBUBj 
the right one being ulcerated on the surface, raised a quarter 
of an inch from the level of the mucous membrane and 
running obliquely downwards towards the middle line from a 
point corresponding to the level of the pharyngeal end of the 
Eustachian tube. The upper end of each growth is too high 
to be seen ; the lower extends nearly three quarters of au inch 
below the soft palate, and follows the Hoe of the salpingo- 
pharyngeal fold. On touching the light one with a probe, a 
paroxysm o£ most violent pain was produced, flying up into the 
right ear ; the left one was far less sensitive. 

The treatment consisted of rubbing each spot with nitrate 
of silver (which was done with the greatest difficulty) and 
ordering an alum gargle and iron and quassia mixture. This 
was continued till January 13th, 1881, when the last note 
entered was " No pain ; the swellings still visible but very 
slight." The patient ceased to attend. 

Cases. Granular pharynffitia ; severe dysphagia ; adenoids 
of nasO'pharynx ; treatment by crushing and scraping (From 
the report of Mr. A. W. Claek).— Mary Ann W— , Bet. 27, 
out-patient June 13th, 18S1, In-patient, Martha Ward, 
under Mr. Golding Bird, June 18th^!2nd, 1881. A thin, 
aniemiCj and cachectic woman, who last year had typhoid 
fever, since which time she had never been really well. 

On June 13th she came to Mr. Gkilding Bird's out-patients, 
complaining of having for the last three weeks stuffiness in 
the right nostril and inability to swallow solids, because of 
great pain in the throat, and warm liquids as they at once came 
up through her nose. Talking was very painful and for two 
weeks she had subsisted on cold milk and arrowroot. There 
had been no anterior nasal discharge, no posterior that she 
knew of, no ozsena, no polypus. 

On examination, the posterior wallof the pharynx was covered 
with a nasal discharge of muco-pus ; this being washed away, 
there was seen a generally granular conditioa of the mucous 
membrane, and on either side, projecting forwards about a 
quarter of an inch, and running down in the direction of the 
Eustachian tube nearly parallel with the posterior pillars, was a 
club-shaped, red granular mass, as of bypertrophied adenoid 
tissue. It was not ulcerated bat very tender ; that on the 



, GoeK^Ic 



446 On Chrome Natal Obstruction. 

right side causing stabbing pain in the right ear when touched ; 
she had the same ear-paia also on BvalloiriDg. 

The right ooatril was fonnd absolutely blocked ; the left free 
to air. There was lerj marked dead intonatioD. Digital 
examioRtioa showed large amoont of granular adenoid growth 
on the right half of the posterior wall of the naso-pharynx; 
only a little on the left. 

She was ordered a gargle of alum and carbolic acid, and a 
mixtnre of iron and quassia. 

On jQDe 18th, when admitted for a few days, she was so 
much improved locally and generally that the same treatment 
was continued ; she conld eat solids and only occasionally 
did liquids return by the nose. 

21st. — The naso-pbarynx was treated with Catti's forceps. 
Some of the growth coming away in tbe instrument. There 
was free bleeding but not much pain. 

22nd. — " Can breathe through both nostrils. Her food 
is not returned through the nose. She can talk much 
better." 

The last note of the case is July 4th, 1881. "Came to 
out-patients' ?ery nearly veil ; all symptoms gone ; patches 
on throat scarcely visible; can breathe well through both 
nostrils. Fine adenoid granulation being still felt, tbe naso- 
pharynx TTas again scraped." 



Dig lized^y Google 



STATISTICAL ACCOUNT 

OF TSB 

SUEGICAL TREATMENT OF ANEURISM. 

COLLECTED FBOH THE HOSPITAL KE00BD8. 



By CHABTEBS J. STM0ND8, M.S. 



Full reports of all the cases under treatment in the surgical 
wards have been made since 1866. Prom this source the fol- 
lowing statistics have been collected, with the consent and 
approval of the surgical staff, and comprise the years 1866 — 80 
inclusive. As the paper deals pareljr with the su^cal treat- 
ment of the affection, only those cases submitted to such pro- 
cedure are included. Thus are omitted, several aneurisms 
involviiig the lai^e arteries at the root of the neck, with or 
without the aorta, also a case of iliac, and another of femoral 
aneurism, in which no treatment was employed ; in one case 
owing to the patient suddenly diaappeariug, and in the other to 
the general arterial, and cardiac disease. 

There are three cases of traumatic aueurism following a pnnc 
ture of the vessel, two occnrring in the radial and one in the 
temporal, which have been omitted. They were all slight cases 
and were treated by incision and' ligature. Though the cases 
here collected include all those recorded in the volumes, it is 



DigtizedoyGoOglf 



44S 



Surgical Treatment qf Aneurism. 



possible that a few jn&y have been unreported, and that lome 
reports may have been lost. Thtf surgeons have been kind 
enougb to examine the tables, and to add, where possible^ points 
unreported, also to correct the results where these have not 
been clearly and full; recorded. lu this way the accuracy has 
been increased, as well as the value of the record. 

Cases which may have been treated in the medical wards have 
not been collected. 

Excluding those mentioned above, eighty-two remain, and 
have been treated by the following methods : 



CompreasioQ alone 

„ followed by iatrodaction of 

hair into the sac . 

„ followed by Hunterian ligal 

Primary Hunterian ligature . 
Distal ligature .... 
By laying open the sac . 
Primary amputation 



42 

1 
19 

13 



Examining first all the cases treated by ligature, the following 
table shows the particulars of each case. It is arranged in 
three divisions : first, all the Hunterian, next the distal, and, 
lastly, those treated by the old operation. 

The particulars of the pressure employed in those cases, where 
this method preceded the ligation of the vessel, will be given 
when the compression treatment is considered. 



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Surgical Treatment of Aneuriam. 463 

Proceeding to examine this table in the order of the sub- 
divisions, the following plan exhibits the total result of the cases 
of Huntehau ligature. 



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This shows a high mortality, especially after ligature of the 
femoral. On looking into the cause of death in each case, as 
shown in the next table, there will be found sufficient reason 
for reducing this death rate by two, thus bringing the propor- 
tion of deaths to one in four. 



Tablk III. — Showing the cause of death aftet the Hunterian 
operation. 



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Id two of these cases the fatal result was not attributable to 
the operation. In one, the wound had healed, and the patient 
was in good health, but the aneurism remaining fluid, the sac 
was laid open, and just as the operation was completed the man 
succumbed to the anieathetic. In the other, death was due to 
an increase of the cerebral condition existing prior to the ope> 
ration. The patient had hemiplegia and aphasia, and after the 



.„Gooj^lf 



454 Surgical Trtatment of Atteurum. 

operatioD tbere wms s temporary improTement, though the anea- 
rjsm wu situated jort above the bifurcadoa of the common 
carotid. The sufteuing was not limited to the diatribatioD of 
the carotid. 

It is noticeable that oot of the twenty-nine cases of ligatare of 
the main vessels of the lower limb, there is bnt one fatal by 
gangrene. In only one other did gangrene occur, and this was 
localised to the foot, the patient recovering after amputation 
through the leg. This case (No. 18) had been previously sub- 
mitted to compression by Esmarch's bandage, and to the 
extreme congestion, and minute extravasations of blood which 
attended its application, the occurrence of gangrene was attri- 
buted, at least in part. There is also not a single case of sup- 
puration of the sac in these twenty- nine operations. Thisreault 
followed in one of the carotid cases, and aimuhvted acute 
touBillitis. On the eighteenth day there was severe fever, and 
on the twenty-seventh the sac was laid open. This complica- 
tion was preceded by secondary htemorrhsge, which ensued on 
the fifteenth day, and recurred several times; bleeding took 
place also from the sac, six days after it was laid open. 

The proportion of deaths from pyiemia is certainly large, bat 
it will be noticed, on referring to the table, that in none of 
these cases was the " antiseptic" method employed, and in one 
only the catgut ligature. 

Secondary btemorrhage proved fatal in one case out of the 
twenty-nine, and occurred in another, but was arrested by 
enlarging the wound and tying the upper end of the vessel. 
Catgut and antiseptic precautions were used, and a rapid 
recovery followed. 

In all the cases, arrest of pulsation and diminution in size 
took place in the aneurism, and there was no recurrent pulsa- 
tion. 

The sac still remained fluid in one on the thirty-second day, 
and was treated as mentioned above. Amputation was pro- 
posed in the fatal case of gangrene, hut in no other was this 
procedure necessary at the seat of ligature. 

It is interesting next to inquire, how far the main canses of 
death are preventable, and to this question the first table gives 
a striking answer, showing bow the mortality has dimiuished 
with the improved methods of treating wounds, and with the 



Dig zee. y Google 



Surgical TreatmetU of Aneurism. 455 

use of tbe catgnt ligature. Taking tlie Hunterian and distal 
operation only, orj in other words, those in which the vessel 
vas ligatured in its continuity, thirty cases are available for 
examination. Those are included in which, either death was 
directly due to the existence of a wound, or in which the 
patient recovered. 

Of the eight cases excluded, four died from other causes than 
those arising in the wound (Nos. 22, 82, 34, 85). One died 
irom peritonitis on the fourth day, a result independent of the 
form of ligature, though perhaps not of the mode of treatment 
of the wound. The other three were treated by the old plan. 

To this list may be added one other, in which the external 
iliac was tied with silk, the tumour proving to be a pulsating 
sarcoma. Death occurred from secondary hiemorrhage. lu 
one of the " silk " cases (No. 2) the wound was dressed under 
the spray, the end of the ligature at the same time being cut 
short, and the wound closed. 

Of these thirty-one cases, silk was employed in nineteen, 
catgut in twelve. There were six deaths after the use of silk, 
viz. three from pytemia, and three from secondary htemorrhage, 
and in one other this latter complication arose, hut was con- 
trolled. So that, in these seven cases, the complication arose 
owing to the existence of the wound, which was prevented 
closing, on account of the form of ligature employed. This 
gives a mortality of Sl'5 per cent, and 36*8 per cent, of compli- 
cations. 

In the twelve cases treated by catgut, one proved fatal from 
pyemia, and in one other there was slight secondary hiemor- 
rfaage. This gives a mortality of 88 per cent, and 16-6 per 
cent, of complications. 

Antiseptic precautions were ui>ed in four cases, and in the 
other eight the wound was closed, and not disturbed for several 
days. In some of the cases no second dressing was required. 
Neither of the cases in which a complication occurred was under 
the antiseptic method. Now, from these facts the conclusion 
seems to follow, that upon the closure of the wound the success 
of the case in great measure depends.' If this can be secured 

' Ht. Holme* Temarks on this poiat, " We have in tbe HanterisD opention a 
method, whicb almoit alwajs tacceedi if Cbe pali«nt reccvcn from tbe operation," 
• Lancet,' 1874, p. 861, vol. ii. 



.yGOOglf 



456 SuTffical Treatment of Jneuritm. 

without Bupparation, the present statistics prove that the mor- 
tality will be greatly reduced. For, takiDg the cases fatal from 
all causes as epumerated in Table III, together with the one 
last introduced of pulsating tumour, it will be seen that, seven 
oat of the eleven deaths were due to the wound remaining open. 
Excluding from this list No. 16, in which the wound had 
healed, seven deaths out of ten must he attributed to the open 
state of the wound, or a proportion of 70 per cent. 

These numbers, though too few to decide the value of the 
catgut ligature finally, are sufficient to show that the use of 
this material, especially when combined with antiseptic precau- 
tions, is one means at least of reducing the mortality. If No. 
S be added to the cases where the wound was closed, though 
the ligature was of carbolised silk, the advantage of this method 
comes out more strongly. 

It has been found by some that catgut is uncertain, that it 
does not hold long enough to ensure the formation of a good 
coagulum. The twelve cases here recorded exhibit its effects, 
three times on the external iliac, eight times on the superficial 
femoral, and once on the subclavian. In the ten successful 
Hunterian cases, there was never any return of pulsation. 

In one case it will be observed that carbolised silk was used, 
and treated in the same manner as catgut. The wound healed 
readily, and in others it has closed by primary union. This 
completely meets the objection as to the uncertainty of catgut, 
and with a closed wound there is no fear of secondary luemor- 
rhage. To ensure this behaviour with the silk, the antiseptic 
method will probably be more essential than with catgut. 

Some information also may be obtained from the table, as to 
the indneuce of previous compression upon the result of liga- 
ture. Taking still the twenty-nine cases of the Hunterian 
operation in the lower limb for examination, it will be found 
that there was no previous compression in eleven, and of these 
three died. The vessel ligatured in all the fatal cases was the 
femoral, the aneurism being femoral in one and popliteal in two. 

Ligature followed compression in eighteen cases, with five 
deaths. In two the external iliac was tied, in three the femoral, 
and of the latter, in one the aneurism was femoral, in two 
popliteal. 

Case No. 16, in which death occurred from chloroform, most 

Dig lized^y Google 



Surgical Treatment t^ Anetirum. 457 

be considered as a failure only, reducing the mortality after 
primary ligature to two. From the Buccesaful cases after 
secondary ligature one. No. 18, must be counted aa a failure, 
gangrene of tbe foot resulting. 

This giyes of failures — 

After primary ligature ... S or 27-27 per oent. 
„ secondary „ ... 6 or 833 „ 

Taking, for comparisoa with other published statistics, tbe 
cases of popliteal aneurism only, there are thirteen of secondary 
ligature with two deaths and one failure, and four primary 
with one death and one failure. 

The percentage in the first is 22'07 per cent, of failures, and 
15'46 of deaths, an average greatly in fsTour of prerions com- 
pression. This result is, therefore, the opposite of that deduced 
from the total of twenty-nine cases. Mr. Hutchinson,^ who 
speaks in favour of tbe effect of previous compression, gives 
four deaths out of ten cases of primary ligature ; and, according 
to Mr. Holmes, five deaths out ofnineteen cases of ligature after 
compression, or a failure in the latter of 26'31 per cent. Mr. 
Holmes* gives, as tbe result of his tables, a failure of 39*64 per 
cent, in secondary ligature, against 19-48 per cent, in the 
primary. 

Tbe sum of these three tables gives a total of eighty-three 
ligatures following compression with twenty failures, and 112 
of primary ligature with twenty-one failures, a result still 
sbowing, as Mr. Holmes says, " to any one who trusts implicitly 
in figures" previous compression to be unfavorable. 

Mere death-rate, which forms the larger proportion of 
failures, does not seem sufficient ground upon which to test the 
influence of previous compression. For in these twenty<ntne 
cases only two deaths out of the seven are attributable to the 
ligature," the rest being due to complications that might attack 
any wound. Again, the pressure was in all the &tal cases 
except one, of abort duration. Tbe case in which gangrene 
occurred was compressed for nine and a half and ten hours on 
two days ; too short a time, apparently, for any serious injury 
to be inflicted upon the artery or the vein. The longest 

< ■ Hadical llinei and 0>Eetta,' Nor. 29, 1856. 
• ' Lancet,' M»j 1, 1876. 
■ Nm. 10 and 82. 

Dig lizedoy Google 



4S8 Surgical Treatment o/ Aneuritm. 

period was fourteen days, the others ten hours, two days, and 
four days. There was not time in any of these cases, for 
exhaustion to have occurred, sufficient to determine a fatal 
result. Though, therefore, the death-rate is against previoua 
compression, yet, in examining -the mortality more closely, it 
seems that this treatment has had little to do with the failures 
in the present list of cases. The frequency of suppuration ia 
the sac, and return of pulsation, besides gangrene, would appear 
to be the proper grounds upon which to consider the influence 
of previous compression. It does not seem easy to say, 
whether the causes leading to gangrene existed prior to com- 
pression or not. A more careful dissection of the fatal cases, 
with special regard to the condition of the arteries below the 
ligature is necessary, before it can be decided in what cases 
gangrene is likely to follow, even upon primary ligature. If it 
were known, for instance, that the vessels had lost much of 
their elasticity, would not a priori reasoning suggest at least 
a short trial of compression 7 In two of the cases, pressure 
was maintained for thirty-four and thirty-six days ; both 
recovered after ligature. In another case placed in the com> 
pression list, treatment was kept np for six months ; subsequent 
ligature became necessary, and the man recovered. These 
points are mentioned to show, that other facts than mere death- 
rate are necessary, in forming an opinion upon the influence of 
previous compression. 

The other three cases of Hnnterian ligature call for no 
further remark as regards treatment.- 

The old operation of laying open the sac and securing the 
vessel above and below, was performed in three cases. In two 
the aneurism was femoral, in one axillary. The last case died 
shortly after the completion of the operation. The aneurism 
had ruptured through the skin, and a good deal of blood was 
lost prior to the operation. In the other two cases the rupture 
was recent, in one of six days', in the other of about twelve 
hours* duration. In both a catheter was introduced into the 
vessel as an aid in dissecting it out. Both suffered from 
secondary hEcmorrhage, which proved fatal in one, the other^ 
recovering after ligature of the vessel immediately above the 
original seat of operation. 

1 A. deluled Bccoimt U giveo lu the ' Ued.-Chir.Iruu.' for 1867. 



Dig lized^y Google 



Surfficai Treatment of Anetiritm. 469 

Of the three cases of distal ligature the one that recovered 
received distinct benefit. Two years later he was readmitted 
with iucTcaee of symptoms, and refused to have the carotid 
tied. 

Cases treated by compression. — The following table sliows the 
gross result of this method, calculated from which, the success 
is 53*2 per cent. Further on it will be shown that the success 
was really greater. 

Table IV. 



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The ueiit tsble gives particulars of all the cases submitted to 
compressioD only, with one in which horsehair was afterwards 
introduced into the sac. There are here forty-three cases. 
The remaining nineteeo, in which ligature was subsequently 
employed, have already been tabulated, and particulars of the 
compression treatment will be presently given. 



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Surgical Treatment of Aaemritm. 465 

The proportion of success ia sliglitly better than tliat stated 
abovp, as in four cases the pressure vas of short duratioiij other 
conditions demaudlDg the ligation of the vessel. Farticalars of 
the compression in these cases are given below (Noa. 6, 23, 24, 
17), under the heading of "Cases afterwards ligatured," where 
it will be seen that, the pain and increase in the size of the 
tumour in two, the previous diffused condition of the aneurism 
in another, and, in the fourth, the irritable state of the patient, 
were reasons for discontinuing the trial of compression. In 
one it is probable a cure would have resulted, in the others the 
aneurism was probably already too advanced for treatment by 
pressure. Omitting these four cases the success is 56'89 per 
cent. 

The duration averages a little over thirteen days. The 
shortest time is seven hours, though in No. 3, all pulsation was 
arrested in five. The method of summing up the duration of 
treatment, includes the periods of rest between the various 
trials. From this cause, in many inatancea it appears long. 
To give, however, as accurate an account as possible of the time 
during which active treatment was employed, a special column 
has been devoted to this. In examining the records, carefully 
reported as they have been on the whole, here and there it has 
not been possible to make out the exact duration of treatment. 
This applies chiefly to those cases where the weight or tourni- 
quet has been left in charge of the patient. In such cases there 
may be a little inaccuracy, a day or two being unaccounted for 
in the report. The time in these is, however, of less moment 
than in those counted by hours. 

Before passing to the unsuccessful cases, it may be well to 
single out the popliteal aneurisms. There are forty-six. Of 
these twenty-five were cured, a percentage of 54'3. Three of 
the cases demanding early ligature were popliteal ; deducting 
these, the success becomes 68'I per cent. 

Mr. Hutchinson gives forty-six cases with twenty-four cures, 
a percentage of 52*1. Mr. Holmes gives sisty-ux cures in 124 
cases, a percentage of 53'2. The similarity in these results ia 
remarkable. 

Of the twenty-nine unsuccessful cases — 

19 were followed by ligature with fourteen cures. In 
1 twenty feet of horsehair were introduced into the sac. 

'teoogk- 



466 Surgical Treatment of Aneurism. 

7 remained improved or uDimproved. And 
2 died. 

Details of the five unsucceBsM casea of ligature have already 
been given. The effect of the horsehatz was to produce " almost 
complete consolidation of the tumoor."' The patient had val- 
vular disease of the heart, and died of arterial pygemia. Two 
cases died : one (No. 39) was an innominate aneurism under the 
care of Mr. Cooper Forster, by whose kindness I am enabled to 
give the details. The first sign of disease was pain under the 
clavicle, in the right side of the neck, and back of head, three 
years before admission. For three months he had noticed a 
tumour at the root of his neck on the right side. When first 
noticed - it was as large as a walnut, and when he first came 
under observation, there was a pulsatile tumour behind the 
inner third of the clavicle and the sternum. The right pupil 
was smaller than the left, and he had ptosis. He was admitted 
on the Srd of April, 187Sj and for seven days the diet was 
restricted. Five days later chloroform was administered, and 
the carotid compressed by means of a pad held in the hand from 
11 a.m. to 8 p.m. For ^e first two hours a good deal of chlo- 
roform was used, after that a little was sufficient. There was 
much coughing, with intervals of sleep. At 8.10 p.m. the 
breathing nearly ceased and became stertorous. At 9 o'clock 
artificial respiration was resorted to, with galvanism, consider- 
able improvement resulting. No movement was observed to 
take place in the left arm and leg after 9 p.m. The next day 
there were " spasms " on irritation, and a strong pulsation in 
the aneurism. He remained in a comatose condition till 4 
p.m. on the 21st, when he died : just five days and five hours 
from the commencement of pressure. Fifteen months before 
he was admitted, he had a suddenly occurring left hemiplegia, 
&om which he slowly recovered. 

At the inspection, made by Dr. Goodhart, the aneurism 
proved to be innominate. It involved the whole arteiy and 
the root of the carotid. The aortic orifice was enlarged to the 
size of a five-shilling piece. The aorta itself was bulged in places. 
The aneurism had absorbed the origin of the sterno-hyoid and 
stemo-thyroid muscles, but the bone was uninjured. The sac 
was as big as an egg, and was nearly full of laminated old 
' Brjuit'a ' Pnctice of anrgery,* Srd ecL, voL !, p. 406. 



.„Gooj^lf 



Surgical Treattaent of Aneurimt. 467 

coaguluaij like Boaked brovn paper. The subclavian seemed to 
be quite intact, at least half aa inch of it existed between the 
sac and its first branches. Both hemispheres of the brain were 
blood stained, aa if from decomposition, but equally so. Yessels 
not particularly full on either side. On slicing the brain, 
patches of hsemorrhage were found scattered through the cine- 
ritions substance ; some of them were scarcely larger than a 
pin's head, others were aggregated together in masses, equal in 
size to a hazel nut, the interrening brun substance being 
softened. The smaller heemorrhages were all in the cineritions 
substance, and the larger, of course, could not be determined 
by the naked eye to be limited to this part, but they followed 
the outlines of it and probably were so. In the wLdte matter 
the bloody points were numerous, but there was no heemorrhage. 
The extravasation was more considerable on the left side than 
on the right; there was none on the lower surface towards the 
base. The arteries at the base were rather thick walled, but 
not markedly diseased, and contained no emboli. The bron- 
chial tubes were intensely reddened, and contained a yellowish 
purifonn fiuid. Those at the base of the right long markedly 
dilated, with intervening portions of the lung airless. 

The other fatal case occurred in the practice of Mr. Birkett, 
who is good enough to permit its pubUcation here. This was 
an iliac aneurism. The first symptom was a sensation as of the 
" bursting of a vein " in the groin twenty-four days before admis- 
sion. He had no pain, swelling, or inconvenience for eighteen 
days, at the end of which time, a pulsating and painful swelling 
appeared in the groin. When admitted, February 5th, 1869, 
the skin was tense and congested and the thigh oedematons. 
On the 7th the common iliac was compressed for eight hours 
(under chloroform], the pulsation beii^ at times completely 
arrested. At the end of this time the pulsation was not dimi- 
nished. Two days after, there was pain and numbness in the 
leg. On the ISth the pulsation being as forcible as on admis- 
sion, the pressure was reapplied (for six hours), and repeated 
eleven days later for ten hours. The next day it is noted that 
there is slight pulsation in the most prominent part of the 
tumour. He became drowsy, the temperature rose on the 17th 
to 102°, and pneumonia was diagnosed. He died March 3rd, 
six days from the last application of pressure. 

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46d Surgical Treatment of Aneurism. 

The sac was found to extend from two inches above, to fire 
inches below Fouparfs ligament, and to be nearly filled with 
soft coagulum. The abdominal wall was ecchymosed and infil- 
trated with inflammatory material. The common iliac was 
surrounded by adheaive lymph, firmly attaching the lymphatic 
glands to it. No injury was sustained by the intestine, nor 
VB8 there any other lesion which could be attributed to the 



These are the only cases in which any untoward result 
followed the application of pressure, and the details of the post- 
mortem examinations are especially interesting. Although 
pulsation continued in the iliac case, the appearances suggest 
that a cure would have resulted. 

In seven cases this form of treatment failed, and was not 
followed by any other. Short notes of the treatment in each 
case have already been given in the table ; a few additional 
particulars of interest are here recorded. The numbers refer 
to Table 5. 

No. 9. — The aneurism in this case was small. The man 
himself had not observed it. When compression was applied 
the sac had existed six weeks ; no improvement resulted though 
the opposite side was easily cured. It is not improbable that, 
as this aneurism was detected early, the commuDication with 
the artery was large in proportion to the sac. This patient 
refused to submit to ligature. 

No. 31.— The pulsation was noticed by the man after a fall, 
in which he sustained a scalp wound. There appears to have 
been no previous pain, though the disease must have existed 
some little time, at least a few days. He refused to have the 
artery tied. 

No. 21. — The symptoms were first noticed after wreatliug. 
He had also aortic valvular disease. There was a gradual 
improvement in the aneurism, and after six weeks, pulsation 
ceased altogether, and he was discharged "cured." Before he 
left the hospital, however, it was noticed that slight pulsation 
occurred when he put the foot to the ground, and also when a 
splint was applied to straighten the knee. Twenty-five days 
after the cessation of pulsation it recurred, and was again 
arrested for four days. Subsequently the aneurism increased 
in size, but again compression failed. The man now left against 



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Surgical IVealment of jineuriita. 469 

advice, baving been under treatment more or less actively for 
six months. 

No. 16. — In this case pulsation ceased four days after the 
compression vas discontinued. Three days later some pulsa- 
tion, thought to be due to enlarging collaterals, was noticed. 
A month later, when discharged, there was no pulsation, nor 
was there any in the tibial arteries. 

There is no mentioD in this, or in the preceding case, of the 
condition of the swelling. Two months after, he was readmitted 
with returu of the pulsatioD, making the time three months 
&om its cessation. It is not stated bow soon the recurrence 
took place, or what use he made of his leg. Compression was 
again resorted to, with the result of diminishing slightly the 
size. After a stay of three months he was discharged, with 
both aneurisms pulsating, no improTement ever having occurred 
in the left (No. 17). Further treatment — probably ligature 
— was proposed, but was not permitted. The return pulsation 
in this case took place at least a month, and probably more, 
after its cessation. No mention is made of cardiac disease. 

No. 34. — The duration in this case is two months. Four 
weeks previously he sprained his knee, but at first suffered no 
inconvenience. During his stay of six months, the pulsation 
was often controlled, and considerable improvement resulted, so 
that, notwithstanding the subclavian aneurism and the other 
arterial disease, he was for some months able to work. 

For the remainder of this case I am indebted to Dr. Words- 
worth Foole, of Sidcup, who, in reply to an inquiry, has kindly 
furnished the particulars, and has generously allowed me to 
make use of them. 

In 1876, about a year after his discharge from the hospital, 
the aneurism threatened to burst, when Dr. Foole ligatured the 
superficial femoral, using catgut, and closing the wound. Ful- 
sation ceased entirely, and never returned. The progress of 
recovery was very slow, the man being, as Dr. Poole says, 
"upstairs" for four months, during which time there was 
severe pain down the leg. " After this, but not till then, the 
tumour diminished, and gradually got down to a size rather 
more than half what it was before operation," He was able to 
work as a cowkeeper a year after the operation, and continued 
thia employment, with intervals of unfitness for work, till 



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470 Surffieat Dreatment 0/ Aneuriam. 

within three montha of his death, which occurred Angtut 28th, 
1880, This WK8 attributed to aortic aneorism, bat no inspec- 
tion was permitted. Dr. Foole, who saw him s week before 
death, sa^s " that the right popliteal and subdavian aneorisms, 
did not increase or trouble him at any time." Another 
interesting feature in this case is that, eighteen months before 
death, or twenty^eight montha after ligature, " the tamour grew 
again, till it was as large as ever, but no pulsation of it as a 
whole could ever he felt, though the cone still contuned fluid, 
and the beating of a small artery could be detected over one 
part of the swelling at a distance from the cone." This case is 
another success after the nse of catgut, and has not been 
induded in the previous statisticB. The spray was not used. 

No. 88. — No ill result followed the treatment. 

It has still to be explained why pressure failed to cure these, 
and the other nineteen cases. But it will be noticed that in 
four out of the seven, the patients refused further treatment, 
and therefore the cases count as total failures, without the 
opportunity being afforded of ligating the artery, in those 
where it was thought a suitable operation. 

Detail) of the cov^esium in the caiea aflerwarda Matured. 
The numbers r^er to taile I. 

No. 4. — Common femoral. Complete by weight for ten and 
fifteen hours on two days. The anenrism was fusiform. No 
improvement followed, but it rapidly disappeared after the 
ligature of the vessel. 

No. 7. — Femoral (common ?}. Complete by tourniquet to 
eztemal iliac under chloroform for ten hours. No improve- 
ment. The sac was close to Foupart's ligament. 

No. 10, — Femoral (two inches below Foupart's). Partial l^ 
tourniquet for four days. Pulsation continued forcible. 

No. 6. — Femoral. Partial arrest for eight and a half hours, 
on the next day for one hour. The aneurism had been rapidly 
enlarging for three weeks, and had suddenly increased six days 
before admission. The projection of the tumour was diminished 
by the pressure, but the pain was very severe. The pulsation 
was not reduced. 

No. S^. — Popliteal. Digital, complete for ten hooia. The 



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Surgical Treaiment of Aneurism. 471 

tnmoar was harder, and the pulsation less. He was irritahle, 
and could not bear the repetition. The other vessels and the 
heart were healthy. 

No. 24. — Popliteal, Digital, complete, with interraptions ior 
ten hours. The aneurism was very large and extended up the 
inner side of the thigh. The pressure reduced the pulsation and 
pain for a da;, but the next and following days the pain was 
severe, and the swelling iacreased in siae, the skin becoming 
tense and red. The artery was ligatured on the third day after 
compression, and was followed by a rapid cure. 

No. 17J — ^Popliteal. A tourniquet was used for six hours. 
The aDeurism had ruptnred before admission, the calf was 
brawny and oedematous. Compression of the afferent vessel 
arrested pulsation, but did not .diminish the size. The man 
bad a to-and-fro aortic murmur. The low position of the 
swelling suggested an embolic origin. There was some increase 
of the tomour during compression. 

No. 16 .-^Popliteal. Digital, complete for twelve, six, and 
six hours on three days, with a day's interval. Pulsation con- 
tinued, but the tumour was harder. The patient had right 
hemiplegia of recent origin, from which he was gradually 
recovering. No cardiac disease coold be discovered. 

No. 19. — Popliteal. Digital, complete for six and a half, 
and eighteen and a half hours on two days, with a day's interval, 
and nine hours by tourniquet immediately after the second 
digital trial. Very little benefit resulted. 

No. 20. — Popliteal. During eleven days there was pressure 
by tourniquet for twelve hours on eight days, digital for fifteen 
hoars on two days, digital and instrumental for twelve hours on 
one day, with a day's interval. During another ten days, the 
patient controlled the tourniquet for ten to twelve hoars daily. 
After fifteen days' rest digital pressure was employed for about 
twelve hours o